Pima County Community Health Needs Assessment March 2012

Prepared on behalf of Carondelet Health Network, Tucson Medical Center and The University of Arizona Medical Center

Data Analyst: Emily A. Coyle, MPH Student The University of Arizona Mel and Enid Zuckerman College of Public Health ACKNOWLEDGMENT

The University of Arizona Medical Center, Carondelet Health Network and Tucson Medical Center wish to thank the following individuals who contributed time, expertise and valuable input to the Pima County Community Health Needs Assessment:

 Alexandra Adams, Marketing Specialist, UAMC  Michele Barnard, Vice President, Marketing & Communications, The University of Arizona Health Network  Odette Bolano, CEO, Carondelet Health Network  Jessamyn Bowling, MPH Candidate, University of Arizona College of Public Health  Juliet Charron, MPH Candidate, University of Arizona College of Public Health  Andrea Chiasson, Government Relations, United Way of Southern Arizona  Patricia Coyle, President, Coyle Creative Solutions  Kayla DeRosa, Intern, UAMC  Dr. Howard Eng, Assistant Professor, University of Arizona College of Public Health  Mindy Fain, MD, Co‐Director, University of Arizona Center on Aging  Andrew J Gall, MPH Candidate, University of Arizona College of Public Health  Christina Geare, Manager of Community Relations, UAMC  Michal Goforth, Executive Director, Pima County Access Program  Scott Going, Interim Department Head, University of Arizona Nutritional Sciences  Steve Goldschmid, MD, Dean, University of Arizona College of Medicine, Co‐CEO, The University of Arizona Health Network  Taz Greiner, Manager of Community Benefit and Access to Care, Carondelet Health Network  Chuck Huckleberry, County Administrator, Pima County  Maia Ingram, Program Director, University of Arizona College of Public Health  Cheryl Kohout, Communications Coordinator, Tucson Medical Center  Jan Lesher, Deputy County Administrator, Pima County  Brad McKinney, Division Manager, Records and Administrative Services, Pima County Health Department  Karen Mlawsky, Co‐CEO, The University of Arizona Health Network  Jim Murphy, President & CEO, Pima Council on Aging  Christopher O’Connor, MS Candidate, University of Arizona School of Natural Resources  Honey Pivirotto, Assistant County Administrator, Pima County  Judy Rich, CEO, Tucson Medical Center  Dorothy Sawyer, Senior Vice President & CEO, St. Mary’s Hospital  Joe Snell, President & CEO, TREO  Julia Strange, Vice President for Community Benefit, Tucson Medical Center  Andy Theodorou, MD, Co‐CEO, UAMC  Donna Zazworsky, Vice President, Carondelet Health Network

TABLE OF CONTENTS

EXECUTIVE SUMMARY ...... 5 INTRODUCTION ...... 10 KEY INFORMANTS ...... 11 I. PIMA COUNTY GEOGRAPHY, DEMOGRAPHICS AND SOCIAL STATISTICS ...... 15  Population  Unemployment  Poverty level  Education  Race/Ethnicity  Economics

II. ACCESS TO HEALTH CARE ...... 23  Provider Shortages and Medically‐Underserved Areas  Hospitals and Travel and Transportation  Population Healthcare Coverage  Percent Medicaid (AHCCCS) and Medicare

III. HEALTH STATUS OF OVERALL POPULATION AND PRIORITY POPULATIONS ...... 35  Leading (Top 10) Causes of Death  Top 10 Causes of Inpatient Hospital Discharge  Rates of “preventable” hospitalizations

IV. RISK FACTOR BEHAVIORS AND CONDITIONS RELATED TO TOP 10 CAUSES OF DEATH ...... 44  Tobacco use, obesity rates and related behaviors  Screenings utilization rates

V. MATERNAL AND CHILD HEALTH ...... 52  Infant mortality rate  Low birth weight rates  Proportion of women who receive late or no prenatal care  Teen pregnancy rate

3 VI. INFECTIOUS DISEASES ...... 68  Sexually transmitted infection incidence rates (chlamydia, gonorrhea and syphilis)  HIV incidence rate  Tuberculosis incidence rate

VII. NATURAL AND BUILT ENVIRONMENT ...... 78  Air quality annual rating  Access to healthy foods and recreational activities

VIII. SOCIAL ENVIRONMENT ...... 80  Violent crime rate  Housing affordability rate

IX. RESOURCES/ASSETS ...... 81 X. COMMUNITY LEADER FOCUS GROUP ...... 86 XI. KEY INFORMANT ANALYSIS ...... 92 XI. APPENDICES ...... 97  Focus Group Content Analysis Outline  Key Informant Questions and Complete Answers  Methodology

TABLE OF FIGURES

Figure 1: Map of Arizona and Pima County, AZ ...... 15 Figure 2: Unemployment rate in Pima County by Primary Care Area ...... 18 Figure 3: Unemployment rate in Pima County by Primary Care Area – greater Tucson ...... 18 Figure 4: Percent of Pima County population below 200% of Federal Poverty Level ...... 20 Figure 5: Percent of Pima County population under 200% of Federal Poverty Level ‐ Greater Tucson ...... 20 Figure 6: Tucson Pima Enterprise Zone ...... 22 Figure 7: Ratio of Pima County Population to Primary Care Providers ...... 25 Figure 8: Ratio of Pima County Population to Primary Care Providers ‐ Greater Tucson ..... 25 Figure 9: Federal Medically Underserved Areas ‐ Pima County ...... 27 Figure 10: Federal Medically Underserved Areas ‐ Greater Tucson ...... 27 Figure 11: Primary Care Score ‐ Pima County ...... 29 Figure 12: Primary Care Score ‐ Greater Tucson ...... 29 Figure 13: Primary Care Area Transportation Score ‐ Pima County ...... 31 Figure 14: Primary Care Area Transportation Score ‐ Greater Tucson ...... 31 Figure 15: Percent of Population Enrolled in AHCCCS ‐ Pima County ...... 34 Figure 16: Percent of Population Enrolled in AHCCCS ‐ Greater Tucson ...... 34 Figure 17: Top 10 Causes of Death, Pima County, 2010 ...... 37 Figure 19: Youth Cigarette Smoking, Pima County, Arizona and U.S...... 45 Figure 20: Arizona Statewide Substance Abuse Epidemiological Profile, December 2009 .. 46

5 Figure 21: Youth Drug and Alcohol Consumption, Pima County, Arizona, U.S...... 48 Figure 22: 2008 Age‐Adjusted Estimates of the Percentage of Adults Who Are Physically Inactive in Arizona ...... 50 Figure 23: Infant Mortality per 1000 Live Births by Primary Care Area ‐ Pima County ...... 55 Figure 25: Low‐Weight Births per 1000 Live Births by Primary Care Area ‐ Pima County .. 58 Figure 26: Low‐Weight Births per 1000 Live Births by Primary Care Area ‐ Greater Tucson ...... 58 Figure 27: Prenatal Care Beginning in the First Trimester by Primary Care Area ‐ Pima County ...... 62 Figure 28: Prenatal Care Beginning in the First Trimester by Primary Care Area ‐ Greater Tucson ...... 62 Figure 29: Teen Births per 1000 Females Age 14‐19 by Primary Care Area ‐ Pima County 65 Figure 30: Teen Births per 1000 Females Age 14‐19 by Primary Care Area ‐ Greater Tucson ...... 65 Figure 31: County‐Specific Prevalent HIV/AIDS Arizona, 2008 ...... 71 Figure 32: County‐Specific Prevalent HIV/AIDS, and State Population, Arizona, 2008 ...... 72 Figure 33: Percentage of Persons with an Unmet Need for HIV Primary Care, 2006‐2009 . 73

TABLE OF TABLES

Table 1: Key Informants ...... 11 Table 2: Percent of Unemployed Residents in Pima County by Primary Care Area ...... 17 Table 3: Percent of Pima County Population Below 200% of Federal Poverty Level by Primary Care Area ...... 19 Table 4: Primary Care Provider Ratio Pima County Population to One by Primary Care Area ...... 24 Table 5: Federal Medically Underserved Area Score by Primary Care Area ‐ Pima County . 26 Table 6: Primary Care Score by Primary Care Area ‐ Pima County ...... 28 Table 7: Transportation Score and General Hospitals by Primary Care Area ‐ Pima County ...... 30 Table 8: Percentage of Population Enrolled in AHCCCS by Primary Care Area ‐ Pima County ...... 33 Table 9: Top 10 Causes of Inpatient Hospital Discharges by First‐Listed Diagnosis, 2009 ‐ Pima County ...... 40 Table 10: Preventable Hospital Stays for Pima County Residents Aged 65 Years and Over 42 Table 11: Preventable Hospital Stays for Pima County Residents Under 65 Years of Age ... 43 Table 12: Adult Smoking Prevalence ‐ Pima County ...... 44 Table 13: Adult Excessive Drinking ‐ Pima County...... 47 Table 14: Obesity Among Pima County Adults ...... 49 Table 15: Diabetes and Mammography Screening Rates ‐ Pima County ...... 51

6 Table 16: Infant Mortality Rates by County of Residence, Arizona and United States, 2000‐ 2010 ...... 52 Table 17: Infant Mortality Rate per 1000 Live Births by Selected Primary Care Area ...... 54 Table 18: Low Birthweight Births by County of Residence, Arizona, 2000‐2010 ...... 56 Table 19: Low Birthweight Births by Mother's Race/Ethnicity and County of Residence, Arizona, 2010 ...... 57 Table 20: Births by Trimester of Pregnancy Prenatal Care Began and Mother's County of Residence, Arizona, 2010 ...... 59 Table 21: Average Number of Prenatal Visits During Pregnancy According to Selected Characteristics of Newborns and Mothers Giving Birth by County of Residence, Arizona, 2010 ...... 60 Table 22: Percent of Pregnant Women Who Receive Prenatal Care During 1st Trimester by Primary Care Area ‐ Pima County ...... 61 Table 23: Trends in Pregnancy Rates by County of Residence Among Females 10‐17 and 18‐19 Years, Arizona, 1999‐2009 ...... 63 Table 24: Teen Births 14‐19 Years per 1000 Females by Primary Care Area ‐ Pima County ...... 64 Table 25: Births by Mother's Age Group, Race/Ethnicity and County of Residence, Arizona, 2010 ...... 66 Table 26: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010 ...... 69 Table 27: Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010 ...... 70 Table 28: Pima County Historical Data for Selected Sexually‐Transmitted Infections, 2008‐ 2010 ...... 70 Table 29: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010 ...... 74 Table 30: Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010 ...... 74 Table 31: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010 ...... 76 Table 32: Air Quality ‐ Pima County ...... 78 Table 33: Access to Healthy Foods and Recreational Facilities ‐ Pima County ...... 79 Table 34: Homicide Rate ‐ Pima County ...... 80 Table 35: List of Hospitals and Federally‐Qualified Health Centers ‐ Pima County ...... 81

EXECUTIVE SUMMARY Undergoing a Community Health Needs Assessment affords the community a look at the current state of its health, highlighting where the community is doing well and where it can improve. The health assessment shows that Pima County does well in many areas compared to the rest of the state. Pima County residents are more active and more likely to practice healthy habits than residents in the rest of the state. However, both the state and county often fall short of national health benchmarks.

Key areas that require our focus and collaboration as a community include: overcoming barriers inhibiting access to care; providing more mental and behavioral health services; increasing education and awareness of obesity and diabetes; and addressing shortages in primary care providers. There are many other factors, including poverty, that offer ample room for improvement in the county's overall health status.

Active, healthy lifestyle More than 80 percent of Pima County residents report adequate leisure‐time physical activity, which is reflected in an adult obesity rate just besting the national benchmark. Residents have better access to healthy foods and recreational facilities compared with the rest of the state, but those rates are below national benchmarks.

Fewer students and adults in the county are smoking cigarettes compared with the rest of the state. The student rate of smoking is also lower than the national rate. At 16 percent,

8 adults report lower rates of excessive drinking, yet it is still double the national benchmark of 8 percent.

A higher percentage of Pima County residents are screened for diabetes and breast cancer than in the state.

Access to health care Pima County has slightly higher percentages of Medicare enrollees and AHCCCS enrollees than the state, and it has not yet met its Healthy People 2020 target goals for the percentage of residents with any type of health insurance coverage.

The county exceeds the national benchmark in preventable hospital stays for residents aged 65 and older; but a number of areas, including the urban core, had higher rates of preventable hospitalizations for residents under 65.

Pima County is considered a Mental Health Professional Shortage Area (HPSA), while several areas are also considered Federal Medically Underserved Areas or Populations. The areas with the greatest medical underservice are Ajo, Pascua Yaqui and Tohono O’odham Nation.

What is killing us: Death and Disease Rates From 2005 to 2010, Pima County saw the death rate decline for cardiovascular disease (though it ranks 10th out of 15 counties in Arizona). Overall death rates also declined in the same time period for malignant neoplasms, accidental injury, cerebrovascular disease, Alzheimer's disease, influenza and pneumonia.

From 2005 to 2010, Pima County saw an overall increase in death rates for injury by firearms, suicide, diabetes and drug‐induced deaths. In fact, Pima County has one of the state’s highest rates of drug‐induced deaths, ranking 13th among all Arizona counties.

Pima County had a lower tuberculosis rate compared with the rest of the state, a relatively low rate of deaths by accident and a slightly lower homicide rate. In 2010, the county had the highest incidence rate of syphilis cases; and from 2004‐08, it had the third highest emergence rate in Arizona of HIV/AIDS. The county has not yet met its target goals for the incidence rate for either E. coli or salmonella.

Babies Pima County has seen a decrease in infant mortality rates, yet remains slightly higher than the state, and has not yet met its target goals for infant mortality rate or mothers who receive early prenatal care. Still, the county was at an 11‐year low for low‐birth weight births.

Non‐health measures Pima County’s unemployment rate is 8.7 percent, lower than the state of Arizona’s rate of 9.5 percent. Still, significant disparity exists within the county, and many areas, including tribal lands, Ajo and the urban core, have unemployment rates equal or higher than the rest

9 of the state.

The county has a slightly higher percentage than the state of people who live below 200 percent of the Federal Poverty Level, but in many areas, including tribal lands, Ajo and the urban core, the rates are much higher. The most recent report of Arizona Health Matters indicates that 41.4 percent of Pima County renters spend 30 percent or more of their household income on rent, the second highest in the state.

Overall, Pima County has higher air quality ratings than the rest of the state. Pima County meets the national benchmark in terms of air pollution‐particulate matter days, yet does not meet the benchmark for ozone days.

INTRODUCTION

A community health needs assessment is an important tool in understanding the overall health status of a community, in increasing communication among community stakeholders, and in identifying health areas that need to be addressed through programs, policies, or interventions.

The importance of community health needs assessments was reinforced by a provision in the 2010 Patient Protection and Affordable Care Act (PPACA), which requires hospitals designated as tax‐exempt 501 (c) 3 non‐profit organizations, to complete a community health needs assessment every three years and adopt implementation strategies to address the needs identified in the report.

In the fall of 2011, the three major non‐profit health systems in Pima County – Carondelet Health Network, Tucson Medical Center, and The University of Arizona Medical Center – combined efforts to conduct a Community Health Needs Assessment for Pima County. This collaboration allowed for the health systems to work closely with one another, bring together key members of the community, and share resources to complete the assessment. The IRS expects that hospitals will conduct a community health needs assessment defined by a particular geographic area. For the purposes of this assessment, the three health systems determined that the geographic scope of the assessment would include all of Pima County, where at least 80 percent of the hospitals’ patients served are located.

10 As the first Community Health Needs Assessment for Pima County conducted by the health systems, this report may serve as a foundation for future assessments that wish to explore different and/or targeted health needs or populations. This report highlights areas that may warrant additional inquiry.

Regarding next steps, each health system will complete a community benefit report that will document the health issues identified in this assessment, and an implementation plan to address the health needs of the community. The plan should include a prioritized description of all the community health needs identified through the assessment and whether/how the hospital intends to address them. This combined effort also allows for more coordinated efforts between the three health systems, the county and community organizations to create coordinated programs to address public health needs.

KEY INFORMANTS

Through an open‐ended written questionnaire, this assessment took into account input from the following key informants who represent the various needs and interests of Pima County. The health systems greatly appreciate the time, expertise, and valuable input of the following individuals:

Table 1: Key Informants

Role, Special Name Title Affiliation Knowledge, and/or Expertise 25 years’ experience Pima Council on Debra Adams COO working with the older Aging adults of Pima County. University of Urban American Director, Arizona Indian/Navajo Agnes Attakai Health Zuckerman Nation living in Disparities College of Public Pima County, not Health urban Tucson

11 30 years in behavioral health system Behavioral Pima County administration and Pat Benchik Health Medical and affordable housing and Administrator Health Services job development for disadvantaged populations Works with all ethnic Caregiver Pima Council on backgrounds and many Suzy Bourque Specialist Aging with inadequate insurance Serves low‐income, Director of Marana Health Mary Carter medically‐underserved Special Projects Center Healthcare populations Pima County Parts of county are Sherry Daniels, Director Health designated as HPSA MS, MPH, RN Department and Federal MUA/P Chief of Serves low‐income, Marana Health Dr. Michael Ellis Behavioral medically‐underserved Center Healthcare Health populations Serves low‐income, Clinical Marana Health Dawn Godowski medically‐underserved Supervisor Center Healthcare populations Role, Special Name Title Affiliation Knowledge, and/or Expertise Serves uninsured residents of Pima County, 72 percent of Executive Pima Community members are Michal Goforth Director Access Program minorities; background in healthcare with Pascua Yaqui and Fort Mojave Indian Tribes Serves population El Rio Health mostly at or below the Executive Brenda Goldsmith Center Federal Poverty Level; Director Foundation works with Pascua Yaqui tribal members

12 26 years in public Whitemore education; 59 percent Kristine Hansen Principal Elementary of student population School receive free or reduced meals Advocacy group Children's Action services all of Arizona's Penelope Jacks Director Alliance, children, focused on Southern AZ underserved children Director, Pima County Parts of county are Department of Department of Larry Kraus designated as HPSA Institutional Institutional and Federal MUA/P Health Health Healthcare HealthSouth Director of administration; Rehabilitation Marie Marchal Business populations with Institute of Development difficulty accessing Tucson healthcare Practicing physician Pima County with provider and Chief Medical Dr. William Martz Medical and health plan Director Health Services administrative experience

Role, Special Name Title Affiliation Knowledge, and/or Expertise Refugees ‐ a medically‐ International underserved, low‐ Medical Case Rescue Jennifer Pashley income, minority Manager Committee in population with special Tucson medical needs 36 years of health experience in provider Assistant and health plan County Pima County Honey Pivirotto, operations and Administrator Medical and MBA financing systems, for Health Health Services regulatory oversight Policy with nearly 13 years with Pima County Health Living Works with individuals Pima Council on Karen Ring Program with chronic health Aging Coordinator conditions Refugees ‐ a medically‐ Well‐Being International underserved, low‐ Lauren Schroeder, Promotion Rescue income, minority MPH Program Committee in population with special Coordinator Tucson medical needs 25 years working with disabled, low‐income, Yolanda Sevillano, Pima Council on Case Manager elderly, medically‐ MA Aging underserved and minority populations University of Arizona Represents low‐income Shannon Future Health Zuckerman population and Native Whitewater Educator College of Public American population Health

14 I. PIMA COUNTY GEOGRAPHY, DEMOGRAPHICS AND SOCIAL STATISTICS

Note: With the exception of the Primary Care Area Statistical Area data, much of the following geography, demographic and social statistics profile was provided for use in this assessment courtesy of the Pima County Health Department on Dec. 14, 2011.

Figure 1: Map of Arizona and Pima County, AZ

Geography and History: Pima County, located in Southern Arizona, is adjacent to six other Arizona counties and shares an international border with Mexico. The counties are Cochise to the east, Graham to the northeast, Maricopa to the north, Pinal to the north, Santa Cruz to the southeast, and Yuma to the west. The international border to the south is with the State of Sonora, Mexico. The border is approximately 123 miles long, with approximately 62 miles of that border located on Tohono O’odham Nation land. Ports of entry are Sasabe, AZ (Sasabe, Sonora Mexico) and Lukeville, AZ (Sonoyta, Sonora Mexico).

Pima County, the second largest of the four original Arizona counties, was created in 1864 and included approximately all of Southern Arizona acquired from Mexico by the Gadsden Purchase. Settlement of the region goes back to the arrival of the Spanish, in the 1690s, who encountered indigenous people already living there.

Around the middle of the 18th century, silver and gold were discovered and prospectors from Mexico entered the area in droves. The latter part of the century saw an expansion of mining and ranching in Pima County and an increase in population.

The Royal Presidio de San Augustín del Tucson was completed by 1781, and it remained the northern‐most outpost of Mexico until the arrival of American soldiers in 1856. From a population of 395 in 1820, Tucson has grown to become the second largest city in

15 Arizona. It has always served as the Pima County seat and was the Arizona Territorial capital from 1867 to 1877. Just south of Tucson is the Mission of San Xavier del Bac, founded in 1697 by Father Kino and is still in use today.

Although greatly reduced from its original size, Pima County still covers 9,184 square miles. It ranges in elevation from 1,200 feet to the 9,185‐foot peak of Mount Lemmon. Within Pima County are two cactus forests – Saguaro National Park to the northeast and Organ Pipe Cactus National Monument in the southwest.

Climate: Southern Arizona is dominated by a mild, high desert environment that makes Pima County a popular travel and relocation destination for people from colder and cloudy climates. Although summers can be scorching, the climate is relatively temperate with low humidity and an average high temperature of 82 and a low of 54 in Tucson. Annual monsoons during July and August contribute most of the region’s annual precipitation, which totals less than 12 inches. Given the size and topographic variety in the county, the local climate can vary significantly.

January January July July Average Average Average Average High (°F) Low (°F) High (°F) Low (°F) Ajo 64.0 41.5 103.0 77.7 Tucson 65.5 37.6 100.1 73.9 Mt. Lemmon 50.6 31.7 92.0 68.9

People: Pima County at a Glance, 2010i Population 980,263 Unemployment (Tucson, December 2010)ii 8.3% Median household income $45,885 Families living below povertyiii 22.8% Individuals living below povertyiv 18.9% Foreign born 13.2% Speak language other than English at home 28.0%

Unemployment: According to 2010 Primary Care Area (PCA) Statistical Profiles, Pima County has an unemployment rate of 8.7 percent, lower than the state rate of 9.5 percent. The PCAs with the higher percentages of unemployment than the county are the following: Ajo, Arivaca, Pascua Yaqui, Tanque Verde, Tohono O’odham Nation, Tucson Central, Tucson East, Tucson North Central, Tucson Southeast, and Tucson Southwest.

16 Table 2: Percent of Unemployed Residents in Pima County by Primary Care Area

PCA Percent unemployed

Ajo 15.1 Arivaca 10.2 Catalina 5.4 Continental 8.7 Green Valley 6.3 Marana 6.1 Pascua Yaqui 27.2 Tanque Verde 9.3 Tohono O'odham 34.7 Nation Tucson Central 10.5 Tucson East Central 9.5 Tucson East 9.5 Tucson North Central 10.1 Tucson Northeast 5.7 Tucson Northwest 7.5 Tucson Southeast 9.5 Tucson Southwest 9.1 Tucson West 7.9 *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 2: Unemployment rate in Pima County by Primary Care Area

Figure 3: Unemployment rate in Pima County by Primary Care Area – greater Tucson

PCA Statistical Profiles also provide the percentage of population that falls below 200 percent of the Federal Poverty Level as reported by the U.S. Census American Community Survey from 2005‐2009. The state percentage is 49.2, lower than the Pima County rate of 51.7. PCAs that had higher percentages of the population below 200 percent of the Federal Poverty Level are Ajo, Marana, Pascua Yaqui, Tohono O’odham Nation, Tucson Central, Tucson East Central, Tucson East, Tucson North Central, Tucson Southeast, Tucson Southwest and Tucson West.

Table 3: Percent of Pima County Population Below 200% of Federal Poverty Level by Primary Care Area

Percent < 200% PCA Federal Poverty Level

Ajo 71.4 Arivaca 33.8 Catalina 40.5 Continental 36.6 Green Valley 31.7 Marana 50.2 Pascua Yaqui 104.1 Tanque Verde 29.7 Tohono O'odham Nation 111.1 Tucson Central 98.3 Tucson East Central 66 Tucson East 58 Tucson North Central 82.5 Tucson Northeast 23.9 Tucson Northwest 26 Tucson Southeast 94.4 Tucson Southwest 70 Tucson West 53.3 *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 4: Percent of Pima County population below 200% of Federal Poverty Level

Figure 5: Percent of Pima County population under 200% of Federal Poverty Level – greater Tucson

Pima County Population, 2010v Race/Ethnicity White 87.6% African American 4.0% Native American 3.6% Asian or Pacific Islander 2.7% Other 2.1% Hispanic Heritage 33.7%

Age Under 5 years 6.9% 5 to 9 years 12.8% 10 to 14 years 6.5% 15 to 19 years 6.9% 20 to 24 years 6.9% 25 to 34 years 14.3% 35 to 44 years 12.5% 45 to 54 years 13.7% 55 to 59 years 6.1% 60 to 64 years 5.3% 65 years or older 14.7% Median age 36.8

Educational Attainment, among residents 25 years or older High school graduate or higher 86.4% Bachelor’s degree or higher 29.0%

Within Pima County, there are two American Indian Reservations – the Tohono O’odham Nation and the Pascua Yaqui Tribe and Reservation. The Tohono O’odham Nation is located in the western portion of Pima County and has a total land mass of 4,453 square miles including the San Xavier Indian Reservation. The resident population of the entire Tohono O’odham Nation was 10,787 according to the Year 2000 Census. The San Xavier Indian Reservation is the smaller eastern section of the Tohono O'odham Indian Reservation, and it lies in the southwestern part of the Tucson metropolitan area and consists of 111 square miles of land area. San Xavier has a 2000 census resident population of 2,053 persons. Sells is the capitol of the Nation with a population of 2,799, or 26 percent of the Tohono O'odham population. Total tribal enrollment is estimated to be 23,890.

The Pascua Yaqui Tribe and Reservation is located in the southwestern part of the Tucson metropolitan area and adjacent to San Xavier Indian Reservation. The Pascua Yaqui Reservation has a land area of less than 1.9 square miles, and a 2000 census resident population of 3,315 persons. Total tribal enrollment is estimated to be 6,136 members.

21 Economics: The American Indian reservations account for ownership of 42.1 percent of land located in Pima County. The state of Arizona owns 14.9 percent; the U.S. Forest Service and Bureau of Land Management, 12.1 percent; other public lands, 17.1 percent; and individual or corporate ownership, 13.8 percent.

Figure 6: Tucson Pima Enterprise Zone

Pima County has an Urban Enterprise Zone that includes all of the City of South Tucson, central Tucson, portions of Marana, Sahuarita, parts of Pima County and parts of the Tohono O’odham Nation and Pascua Yaqui Indian Reservation.vi These Urban Enterprise Zones are designated to help encourage economic development in distressed neighborhoods through tax and regulatory relief to investors willing to launch businesses in the area. Pima County is also home to 15 designated Colonias. In Arizona, Colonias encompass all types of communities that meet the federal definition of lacking sewer, wastewater removal, decent housing or other basic services.

Davis‐Monthan (D‐M) Air Force Base borders the southeastern edge of the City of Tucson and falls within the city limits of Tucson. The Base occupies approximately 16.6 square miles of land. The land occupied by D‐M is owned by the United States Air Force, the State of Arizona, the City of Tucson and several private owners. The 355th Fighter Wing is the host unit providing medical, logistical and operational support to all D‐M units. The wing's mission is to train A‐10 and OA‐10 pilots, and provide close support and forward air control to ground forces worldwide. D‐M is also home to the 12th Air Force, the 563rd Rescue Group, the Aerospace Maintenance and Regeneration Group also known as the Aircraft Boneyard and a regional U.S. Immigration and Customs Enforcement complex. These units at D‐M, along with tenet organizations, represent a workforce of 6,100 airmen and 1,700 civilian personnel.

Pima County is also home of the University of Arizona, a large public research university. Founded in 1885, the mission of the University of Arizona is to provide a comprehensive, high‐quality education that engages students in discovery through research and broad‐based scholarship. Home to nearly 39,000 students, the University also employs more than 11,000 staff and faculty. The University brings in approximately $530 million in research to the community and is ranked #16 among all public universities by the National Science Foundation. The University occupies 387 acres in central Tucson, and is the oldest continually‐maintained green space in Arizona.

Pima County is home to eight community hospitals, an Institute for Mental Disease (IMD), Sonora Behavioral Health and the Southern Arizona Veterans Affairs Health Care System. The University of Arizona Medical Center – University Campus (UAMC) is the county’s only Level I Trauma Center. Tucson Medical Center (TMC) and UAMC are the only in‐patient pediatric facilities in the area. St. Joseph’s Hospital, part of the Carondelet Health Network, is the newest neurological facility, joining TMC, UAMC and Northwest Medical Center that also offer this service. Carondelet also manages St. Mary’s and the Carondelet Heart & Vascular Institute. The other two hospitals serving Pima County are The University of Arizona Medical Center – South Campus, which holds a level III trauma license working under the same leadership as the Level 1 Trauma Center and Northwest Healthcare Oro Valley Hospital. Sells Hospital, run by the Indian Health Service, is also located in Pima County but on the Tohono O’odham Nation Reservation and serves only tribal members. Pima County is also home to four Federally Qualified Health Centers, Desert Senita Community Health Center; El Rio Community Health Center; Marana Health Center and United Community Health Center.

II. ACCESS TO HEALTH CARE

Provider Shortages and Medically‐Underserved Areas

Health staffing shortages by Health Professional Shortage Area (HPSA) The federal Health Professional Shortage Area (HPSA) designation identifies an area or population as having a shortage of dental, mental and primary health care providers. HPSA designations are used to qualify for state and federal programs aimed at increasing primary care services to underserved areas and populations. A HPSA designation is based on three criteria, established by federal regulation:  The area must be rational for delivery of health services  A specified population‐to‐provider ratio representing shortage must be exceeded within the area as evidenced by more than 3,500 persons per physician (or 3,000 persons per physician if the area has "high needs")  Health care resources in surrounding areas must be unavailable because of distance, overutilization or access barriersvii

23 Medically Underserved Areas/Populations (MUA/P)  Medically Underserved Areas (MUAs) may be a whole county or a group of contiguous counties, a group of county or civil divisions or a group of urban census tracts in which residents have a shortage of personal health services  Medically Underserved Populations (MUPs) may include groups of persons who face economic, cultural or linguistic barriers to health careviii

Primary Care Area Statistical Profiles provide a ratio of population to provider, as seen in the table and maps below:

Table 4: Primary Care Provider Ratio Pima County Population to One by Primary Care Area

Primary Care PCA Provider Ratio Population to 1 Ajo 705 Arivaca 1445 Catalina 783 Continental 753 Green Valley 432 Marana 1102 Pascua Yaqui 1723 Tanque Verde 659 Tohono O'odham 425 Nation Tucson Central 982 Tucson East Central 152 Tucson East 816 Tucson North Central 181 Tucson Northeast 230 Tucson Northwest 494 Tucson Southeast 1214 Tucson Southwest 1053 Tucson West 3752 *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 7: Ratio of Pima County Population to Primary Care Providers

Figure 8: Ratio of Pima County Population to Primary Care Providers ‐ Greater Tucson

25 According to the State Health Department records, Pima County is a federally designated Health Professional Shortage Area (HPSA) for primary care, behavioral health and dental. The County also is federally designated a Medically Underserved Area (MUA). Twenty‐ seven percent of the population is located in a Primary Care HPSA; 55 percent is located in a dental care HPSA, 100 percent is in a low‐income behavioral health HPSA and 31 percent in a medically underserved area. The following table shows the Federal MUA/P scores for the Primary Care Areas in Pima County:

Table 5: Federal Medically Underserved Area Score by Primary Care Area ‐ Pima County

PCA Federal MUA/P

Ajo 54.4 Arivaca 52.3 Catalina No Continental 52.3 Green Valley 52.3 Marana 62 Pascua Yaqui No Tanque Verde No Tohono O'odham Nation 57.1 Tucson Central 58.7 Tucson East Central No Tucson East No Tucson North Central 58.7 Tucson Northeast No Tucson Northwest 62 Tucson Southeast 58.7 Tucson Southwest 58.7 Tucson West No *A score of 62 or lower is considered a Federal MUA/MUP. *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 9: Federal Medically Underserved Areas ‐ Pima County

Figure 10: Federal Medically Underserved Areas ‐ Greater Tucson

27 Primary Care Areas are given a Primary Care Index Score, which is the totaled score of 14 weighted items including points given for ambulatory sensitive conditions, provider‐to‐ population ratio, transportation score, percentage of population below poverty, percentage of uninsured births, low birth weight births, prenatal care, percentage of deaths before the U.S. birth life expectancy, infant mortality rate, and percent minorities, elderly and unemployed. Primary Care Areas scoring in the top 25% or having a score greater than 55, whichever is greater, are designated as medically underserved. Additionally, by Arizona Statute, all federally designated Arizona Primary Care Health Professional Shortage Areas (HPSAs) are also considered AzMUAs. The three Primary Care Areas with the highest score (and subsequently the greatest medical underservice) are Ajo, Pascua Yaqui and Tohono O’odham Nation.

Table 6: Primary Care Score by Primary Care Area ‐ Pima County

PCA Primary Care Score

Ajo 62 Arivaca 26 Catalina 28 Continental 28 Green Valley 38 Marana 32 Pascua Yaqui 64 Tanque Verde 20 Tohono O'odham Nation 74 Tucson Central 42 Tucson East Central 34 Tucson East 42 Tucson North Central 46 Tucson Northeast 14 Tucson Northwest 16 Tucson Southeast 46 Tucson Southwest 40 Tucson West 40 The higher the score, the greater the medical underservice. *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 11: Primary Care Score ‐ Pima County

Figure 12: Primary Care Score ‐ Greater Tucson

29 Hospitals and Travel and Transportation – Getting to Care

Having a hospital nearby and adequate transportation increase access to care when people need it most.

Transportation Score: Transportation is critical in terms of accessibility of health care. Many populations, including low‐income, rural, elderly and disabled, face challenges with transportation to health care. Statistical Profiles provide transportation scores for each PCA. Adequacy of transportation is determined by the transportation score. The Arizona statewide transportation score is 150; the overall Pima County score is 93. The higher the score, the less adequate or greater the need for transportation.

General Hospitals: “Yes” means that there is a short‐stay, acute care, non‐federal, non‐Indian, general hospital within a driving time of 35 minutes or less. “No” means there is no facility within the driving time for County, Region, and State, number of short‐stay, acute care, non‐federal, non‐Indian, general hospitals. County‐wide, Pima has 2.1 hospital beds per 1,000 residents, equivalent to the state rate.

Table 7: Transportation Score and General Hospitals by Primary Care Area ‐ Pima County

PCA Transportation Score General Hospitals

Ajo 144 No Arivaca 99 Yes

Catalina 87 Yes Continental 92 Yes Green Valley 166 No

Marana 91 Yes Pascua Yaqui 178 Yes Tanque Verde 85 Yes

Tohono O'odham Nation 286 No Tucson Central 101 Yes Tucson East Central 86 Yes

Tucson East 82 Yes Tucson North Central 109 Yes Tucson Northeast 76 Yes

Tucson Northwest 78 Yes Tucson Southeast 111 Yes Tucson Southwest 100 Yes Tucson West 97 Yes *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 13: Primary Care Area Transportation Score ‐ Pima County

Figure 14: Primary Care Area Transportation Score ‐ Greater Tucson

31 Population Healthcare Coverage

The Arizona Health Matters website reports on whether counties meet population health goals set forth by the federal government’s Healthy People 2020 program. U.S. Healthy People 2020 is a comprehensive set of key disease prevention and health promotion objectives. (NOTE: The Arizona Department of Health Services (AZDHS) updated its vital statistics with 2010 data in February of 2012. The Arizona Health Matters website, which utilizes data from the AZDHS, had not yet been updated with the 2010 AZDHS data at the time this report was written, and is based on 2009 AZDHS data.)

ADULTS AND CHILDREN WITH HEALTH INSURANCE Pima County has not yet met its target goals for the percentage of adults aged 18‐64 years and children aged 0‐17 years who have any type of health insurance coverage. The current percentage of adults with health insurance coverage is 79.8 percent, and 88.5 percent for children; the target set under Healthy People 2020 is to increase the proportion of people with health insurance to 100 percent. There has not been a significant increase or decrease in health insurance coverage status since the last measurement.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Medical costs in the United States are extremely high, so people without health insurance may not be able to afford medical treatment or prescription drugs. They are also less likely to get routine checkups and screenings, so if they do become ill they will not seek treatment until the condition is more advanced and therefore more difficult and costly to treat.”ix

Percent Medicaid (AHCCCS) and Medicare:

Pima County has a slightly higher percentage of residents who are enrolled in Medicare – 14.1 percent – compared to Arizona (12.8 percent). Data on Medicaid (AHCCCS) enrollment is available by Primary Care Areas. The percentage of Medicare enrollees is provided for the county, based on 2007 estimates from the Centers for Medicare and Medicaid Services. The AHCCCS data is the percent of 2010 population enrolled in AHCCCS Program.x

The highest percentages of AHCCCS enrollees (>30) in Pima County are located in the following Primary Care Areas: Ajo, Tohono O’odham Nation, Tucson Central, Tucson North Central, Tucson Southeast, Tucson Southwest and Tucson West.

32 Table 8: Percentage of Population Enrolled in AHCCCS by Primary Care Area ‐ Pima County

AHCCCS Enrollees PCA (Percent)

Ajo 33.2 Arivaca 14.4 Catalina 9.3 Continental 16.2 Green Valley 5.8 Marana 19.7 Pascua Yaqui 34 Tanque Verde 14.4 Tohono O'odham Nation 49.1 Tucson Central 35.5 Tucson East Central 26.5 Tucson East 27.7 Tucson North Central 30.1 Tucson Northeast 8.3 Tucson Northwest 13.6 Tucson Southeast 42.3 Tucson Southwest 33.6 Tucson West 30.2 *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 15: Percent of Population Enrolled in AHCCCS ‐ Pima County

Figure 16: Percent of Population Enrolled in AHCCCS ‐ Greater Tucson

34 III. HEALTH STATUS OF OVERALL POPULATION AND PRIORITY POPULATIONS

Below are the top 10 causes of death in Pima County for 2010. Pima County is ranked among the state’s 15 counties from 1 to 15; a ranking of #1 signifies best health outcomes, and a ranking of #15 signifies the worst health outcomes among counties.

Leading (Top 10) Causes of Death

Top 10 Causes of Death in Pima County, 2010 *By Age Adjusted Rates DEATHS PER 100,000 RESIDENT POPULATION (BOTH GENDERS):

PIMA: ARIZONA: PIMA’S RANK** AMONG 15 AZ COUNTIES: CAUSE 1: Cardiovascular Disease 191.8 188.6 #10  Diseases of Heart 143.0 143.3  Coronary Heart 98.8 112.9 Disease

CAUSE 2: Malignant Neoplasms 156.1 150.5 #9  Lung cancer 35.9 38.1  Colorectal cancer 15.3 13.8  Malignant melanoma 2.4 2.8 of the skin

CAUSE 3: Accident (unintentional 42.8 43.8 #4 injury) 18.0 14.0  Motor vehicle accident 10.3 11.1  Accidental falls 9.1 11.5  Accidental poisoning 0.6 1.3  Accidental drowning

CAUSE 4: Chronic lower respiratory 43.9 42.6 #7 diseases

CAUSE 5: Cerebrovascular disease 34.0 30.7 #10

CAUSE 6: Drug‐induced deaths 21.4 17.6 #13

CAUSE 7: Diabetes 20.2 20.1 #7

35 PIMA: ARIZONA: PIMA’S RANK** AMONG 15 AZ COUNTIES:

CAUSE 8: Alzheimer’s Disease 19.3 35.1 #7

CAUSE 9: Intentional self‐harm 16.9 16.7 #8 (suicide)

CAUSE 10: Injury by firearms 16.9 14.2 #10

AVERAGE AGE AT DEATH: 72.9 72.1 #13

MEDIAN AGE AT DEATH: 77.0 77.0 #9

*Adjusted to the 2000 standard U.S. population. The causes of death for 2010 are classified by the Tenth Revision of the International Classification of Diseases (ICD‐10). Data are compiled from Table 5E‐11: Age‐Adjusted Mortality Rates for Selected Leading Causes of Death and Average Age at Death from All Causes by County of Residence, Arizona, 2010,” ADHS Bureau of Public Health Statistics, Health Status and Vital Statistics Section. http://azdhs.gov/plan/report/ahs/ahs2010/5e.htm.

**Rank from lowest rate to highest.

Of note, Pima County has the third‐highest age‐adjusted death rate in Arizona for drug‐ induced deaths. Pima’s age‐adjusted death rates were higher than the rest of the state in the following categories: cardiovascular disease, malignant neoplasms, chronic lower respiratory diseases, cerebrovascular diseases, diabetes, suicide and injury by firearms.

Figure 17: Top 10 Causes of Death, Pima County, 2010

SOURCE: http://www.azdhs.gov/plan/report/ahs/ahs2010/5e.htm *Adjusted to the 2000 standard U.S. population. Note: All rates are per 100,000 resident population.

Trends in Age‐Adjusted Death Rates for Top 10 Causes of Death

From 2005 to 2010, Pima County saw an overall decline in the age‐adjusted death rate for cardiovascular disease, with the rate ranging from 242 deaths per 100,000 population in 2005 to 191.8 deaths per 100,000 population in 2010. From 2005 to 2006, the age‐ adjusted death rates for malignant neoplasms dropped from 171.2 to 157.4 deaths per 100,000 population and remained mostly stable over the next several years, with the latest data showing 156.1 deaths per 100,000 in 2010. The rate of accidental injury dropped from 51.3 deaths per 100,000 population in 2005 to 42.8 deaths per 100,000 population in 2010. The age‐adjusted death rates for cerebrovascular disease, Alzheimer’s disease, and influenza and pneumonia also saw an overall decline.

During the same time period, Pima County has seen an increase in the age‐adjusted death rates for injury by firearms (14.1/100,000 population in 2005 compared to 16.9/100,000 in 2010); intentional self‐harm (suicide) (15.6/100,000 population in 2005 compared to 16.9/100,000 population in 2010); diabetes (18.3/100,000 population in 2005 compared to 20.2/100,000 population in 2010); and drug‐induced deaths (18.5/100,000 population in 2005 compared to 21.4/100,000 population in 2010).

Figure 18: Top 10 Causes of Death, Pima County, 2005‐2010

SOURCE: http://www.azdhs.gov/plan/report/ahs/ ‐ 2005 to 2010 data.

*The 10th cause of death alternated between influenza/pneumonia and injury by firearms during the time period measured.

The Arizona Health Matters website reports on whether counties meet population health goals set forth by the federal government’s Healthy People 2020 program. U.S. Healthy People 2020 is a comprehensive set of key disease prevention and health promotion objectives. The following selected indicators related to top 10 causes of death show areas where Pima County has not yet met the target goals set forth by Healthy People 2020. (NOTE: The Arizona Department of Health Services (AZDHS) updated its vital statistics with 2010 data in February of 2012. The Arizona Health Matters website, which utilizes data from the AZDHS, had not yet been updated with the 2010 AZDHS data at the time this report was written, and is based on 2009 AZDHS data.)

INJURY AND VIOLENCE PREVENTION

AGE‐ADJUSTED DEATH RATE DUE TO FIREARMS: Pima County has not yet met its target goal for the age‐adjusted death rate due to firearms per 100,000 population. The current rate is 14.0 deaths per 100,000 population; the target

38 goal under Healthy People 2020 is 9.2 deaths per 100,000. However, the rate has been decreasing over time.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Firearm deaths include intentional use (e.g. homicide), unintentional discharge and suicide. In the 1980s, gun violence became a national concern and continues to be a serious problem to this day. According to the National Institute of Justice, initial federal gun‐crime prevention efforts focused on getting illegal guns off the streets and out of the hands of urban youth. However, over 20 years of intervention research has shown that in order to reduce gun violence, efforts must address both the demand and supply of firearms. Successful interventions have elements of federal‐ local law enforcement collaboration, community involvement and targeted intervention tactics.”xi

PEDESTRIAN DEATH RATE: Pima County has not yet met its target goal for the number of pedestrian deaths killed in traffic collisions per 100,000 population. The current rate is 1.8 deaths per 100,000 population; the target goal under Healthy People 2020 is 1.3 deaths per 100,000 population. However, the rate has been decreasing over time.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “In 2008, 4,378 pedestrians were killed in traffic crashes in the United States. On average, a pedestrian is killed in a traffic crash every 120 minutes and injured in a traffic crash every 8 minutes. There were 69,000 pedestrians injured in traffic crashes in 2008 in the United States. In 2008, one‐fifth (20%) of all children between the ages of 5 and 9 who were killed in traffic crashes were pedestrians.”xii

MENTAL HEALTH AND MENTAL DISORDERS

AGE‐ADJUSTED DEATH RATE DUE TO SUICIDE: Pima County has not yet met its target goal for the age‐adjusted death rate per 100,000 population due to suicide. The current rate is 16.4 deaths per 100,000 population; the target goal under Healthy People 2020 is 10.2 deaths per 100,000. The rate has increased since the last measurement.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Suicide is a major, preventable public health problem. In 2007, suicide was the 11th leading cause of death in the United States. Based on 2007 age‐adjusted death rates, men were nearly four times more likely to die of suicide than females, and white individuals were more than twice as likely to die of suicide than black or Hispanic individuals. Older Americans are disproportionately likely to die by suicide. An estimated eight to 25 attempted suicides occur per every suicide death.”xiii

39 Table 9: Top 10 Causes of Inpatient Hospital Discharges by First‐Listed Diagnosis, 2009 ‐ Pima County

RANK NUMBER NUMBER OF DIAGNOSIS DISCHARGES CATEGORY* 1 15,305 Diseases of the circulatory system 2 11,487 Diseases of the digestive system 3 9,984 Injury and poisoning 4 9,188 Diseases of the respiratory system 5 7,650 Diseases of the musculoskeletal system 6 6,042 Mental disorders 7 5,831 Diseases of the genitourinary system 8 4,861 Neoplasms 9 4,437 Symptoms, signs and ill‐defined conditions 10 3,985 Endocrine nutritional metabolic and immunity diseases

(Source: Arizona Department of Health Services, Hospital Inpatient and Emergency Room Statistics by First‐Listed Diagnosis, 2009 ‐ http://azdhs.gov/plan/hip/by/diagnosis/index.htm)

Notes: An inpatient discharge occurs when a person who was admitted to a hospital leaves that hospital. A person who has been hospitalized more than once in a given calendar year will be counted multiple times as a discharge and included more than once in the hospital inpatient discharge data set; thus, the numbers in this report are for discharges, not persons. All county‐level data are based on patient zip code of residence and not the location of hospitalization. Federal, military and Department of Veteran Affairs hospitals are excluded. All discharges are for the residents of Arizona. Discharges of out‐of‐state residents are not included in this report. Discharges of inpatients exclude newborn infants.

40 *Categories include the following:

Diseases of the circulatory system Mental disorders  Heart disease  Psychoses o Acute myocardial infarction o Alcoholic psychoses o Coronary atherosclerosis o Drug psychoses o Other ischemic heart disease o Schizophrenic disorders o Cardiac dysrhythmias o Manic‐depressive disorders . Cardiac arrest  Neurotic disorders o Congestive heart failure o Anxiety states  Cerebrovascular disease o Depression o Drug dependence Disease of the digestive system o Nondependent abuse of  Appendicitis drugs  Noninfectious enteritis and colitis o Alcohol dependence  Diverticula of intestine syndrome  Cholelithiasis Diseases of the genitourinary system Injury and poisoning  Calculus of kidney and ureter  Fractures, all sites o Fracture of neck or femur Neoplasms  Poisonings  Malignant neoplasms o Large intestine Diseases of the respiratory system o Prostate  Acute bronchitis and bronchiolitis o Trachea bronchus and lung  Pneumonia o Breast  Chronic bronchitis  Benign neoplasms  Asthma Endocrine nutritional metabolic and Diseases of the musculoskeletal system immunity diseases  Osteoarthrosis and allied disorders  Diabetes mellitus  Invertebral disc disorders  Volume depletion  Morbid obesity

41 Rates of “preventable” hospitalizations

Table 10: Preventable Hospital Stays for Pima County Residents Aged 65 Years and Over

PREVENTABLE HOSPITAL STAYS FOR PIMA RESIDENTS AGED 65 YEARS AND OVER

Error Pima Margin + or County – 3% National Benchmark* Arizona

Hospitalizations for Ambulatory Care Sensitive 47 46‐49 52 53 Conditions, 2006‐2007

DEFINITIONS:

 According to County Health Rankings, “Preventable hospital stays are measured as the hospital discharge rate for ambulatory care‐sensitive conditions per 1,000 Medicare enrollees.xiv This indicator is often used to assess the effectiveness and accessibility of primary health care.xiv Two studies analyzing the association between self‐reported accounts of individuals’ access to medical care with hospital admissions rates for ambulatory‐care sensitive conditions (ACSC) found that individuals who reported poor access to medical care had higher hospitalization rates for ACSC.xiv”  Ambulatory care sensitive conditions are illnesses that can often be managed effectively on an outpatient basis and generally do not result in hospitalization if managed properly. Examples include diabetes, asthma, chronic obstructive pulmonary disease, hypertension and invasive cervical cancer.xv

Pima County had a rate of 47 discharges for ACSCs per 1,000 Medicare enrollees during the 2006‐2007 reported year. This rate is below the national benchmark of 52 and also falls below much of Arizona for preventable hospitalizations for ACSCs.

42 Rates of “preventable” hospitalizations for residents under age 65:

According to Primary Care Statistical Profiles for 2010xvi (“Arizona Primary Care Area Statistical Profiles,” Arizona Primary Care Area Program, ADHS ‐ http://www.azdhs.gov/hsd/profiles/profiles1.htm), the following Primary Care Areas had higher rates of preventable hospitalizations than the County rate of 45 preventable hospital stays per 100,000 residents under 65 years of age: Continental, Pascua Yaqui, Tucson Central, Tucson East Central, Tucson East, Tucson North Central, Tucson Southeast, Tucson Southwest and Tucson West:

Table 11: Preventable Hospital Stays for Pima County Residents Under 65 Years of Age

Preventable Hospital Stays for Pima County Residents Under 65 Years of Age

Hospital Admissions for Points Above/Below (‐) PCA ASCS/1000 Residents Statewide Average aged <65 (Arizona = 45) Ajo 32.7 ‐12.4 Arivaca 22.7 ‐22.4 Catalina 22.6 ‐22.5 Continental 51.6 6.5 Green Valley 19.5 ‐25.7 Marana 25.6 ‐19.5 Pascua Yaqui 83.5 38.3 Tanque Verde 38.4 ‐6.8 Tohono O'odham Nation 26.5 ‐18.6 Tucson Central 53.9 8.8 Tucson East Central 54.2 9.1 Tucson East 58.6 13.5 Tucson North Central 53.5 8.3 Tucson Northeast 18.6 ‐26.5 Tucson Northwest 20.2 ‐24.9 Tucson Southeast 60 14.9 Tucson Southwest 57.3 12.1 Tucson West 60.2 15.1

High rates of preventable hospitalizations are often associated with low‐income populations who have poor access to medical care. There is at least one study that has shown a higher preventable hospitalization rate can be found among African Americans and Hispanics regardless of age or gender.xiv

43 IV. RISK FACTOR BEHAVIORS AND CONDITIONS RELATED TO TOP 10 CAUSES OF DEATH

Tobacco use in adults:

Table 12: Adult Smoking Prevalence ‐ Pima County

ADULT SMOKING PREVALENCE

Error Pima Margin + or County – 3% National Benchmark* Arizona

Adult Smoking Prevalence 17% 16‐19 15% 18%

DEFINITIONS:

According to County Health Rankings, Adult Smoking Prevalence is defined as “the estimated percent of the adult population that currently smokes every day or “most days” and has smoked at least 100 cigarettes in their lifetime.” The information is compiled from seven years of data (2003‐2009) of the National Behavioral Risk Factor Surveillance System (BRFSS), a random telephone survey and included a sample size of 5,278 respondents in Pima County with landlines.

Cigarette smoking is associated with many diseases including four of the top five causes of death in Pima County, specifically cardiovascular disease, cancer, chronic lower respiratory diseases and cerebrovascular disease. Pima County currently ranks above the national benchmark for adult smoking prevalence yet is below the statewide average for Arizona.

44 Youth tobacco use:

According to the Campaign for Tobacco‐Free Kids, each year in Arizona 6,000 children under the age of 18 become new daily smokers. Further, 105,000 Arizona youth now under 18 will ultimately die prematurely from smoking. Children are twice as sensitive to tobacco advertising than adults and one‐third of underage experimentation with smoking is due to tobacco company advertising.xvii

Through the Communities Putting Prevention to Work program (CPPW), the Youth Risk Behavior Survey was conducted in 2010 from a sample of 1,300 students from 21 traditional public high schools throughout Pima County. Overall, Pima County has fewer students smoking cigarettes than the rest of the state or the United States when compared with 2009 state and national data. The table below shows the percent of Pima County youth who smoke or have smoked:

Figure 19: Youth Cigarette Smoking, Pima County, Arizona and U.S.

(Source: 2010 Youth Risk Behavior Surveillance Survey, Pima County, Arizona & United States Results Comparison.)

45 The following shows the average age of first cigarette use by county as reported by the Arizona Youth Tobacco Survey, which monitors trends in tobacco use among public school children. Pima County children first used cigarettes between 12.63 and 13.51 years of age.

Figure 20: Arizona Statewide Substance Abuse Epidemiological Profile, December 2009

(Figure 4.15, “Arizona Statewide Substance Abuse Epidemiology Profile, December 2009,” The Substance Abuse Epidemiology Work Group and Bach Harrison, LLC, The Governor’s Office for Children, Youth and Families Division for Substance Abuse Policy‐ http://gocyf.az.gov/sap/documents/2009SAEP/Full2009SAEP.pdf)

46 Alcohol abuse in adults:

Table 13: Adult Excessive Drinking ‐ Pima County

ADULT EXCESSIVE DRINKING

Error Pima Margin + or County – 3% National Benchmark* Arizona

Adult Excessive Drinking 16% 15‐18 8% 17%

DEFINITIONS:

Women and men who consume four or five alcoholic beverages at a given time, respectively, or at least one or two drinks per day, respectively, on average, would be included in the definition of adult excessive drinking.xviii The measure is based on 2003‐2009 data from the Behavioral Risk Factor Surveillance System (BRFSS).

Excessive drinking is related to several adverse health outcomes, including hypertension, suicide, motor vehicle crashes, interpersonal violence, fetal alcohol syndrome and many others. While Pima County falls below the rest of the state at 16 percent of adults reporting excessive drinking, it is double the national benchmark of eight percent.xviii

Alcohol and other drug use in youth:

Through the Communities Putting Prevention to Work program (CPPW), the Youth Risk Behavior Survey was conducted in 2010 from a sample of 1,300 students from 21 traditional public high schools throughout Pima County. The following tables show the rates of drug consumption and exposure and alcohol consumption among Pima County youth compared with 2009 data from the rest of Arizona and the United States:

Figure 21: Youth Drug and Alcohol Consumption, Pima County, Arizona, U.S.

(Source: 2010 Youth Risk Behavior Surveillance Survey, Pima County, Arizona & United States Results Comparison.)

The data shows that while alcohol and other drug use among Pima County high school students is similar to state and national data, a much smaller proportion of Pima County high school students report having ever had at least one drink of alcohol (21.2 percent in Pima County compared to 44.5 percent of Arizona youth and 41.8 percent of U.S. youth), and a much higher proportion report having drank alcohol for the first time before age 13 years (38.2 percent in Pima County compared to 25.6 percent and 21.1 percent statewide and in the U.S., respectively).

In Pima County, 21.4 percent of youth reported using marijuana one or more times, compared to 23.7 percent statewide and 20.8 percent in the U.S. Thirty‐three percent of youth surveyed report having been offered, sold or given an illegal drug by someone on school property, which is similar to the statewide rate of 34.6 percent, but much higher than the U.S. percentage of 22.7 percent.

48 Adult Obesity

Table 14: Obesity Among Pima County Adults

ADULT OBESITY

Error Pima Margin + or County – 3% National Benchmark* Arizona

Percent of adults who 24% 21‐26 25% 24% report a BMI of > = 30

DEFINITIONS:

Adult obesity is defined as having a body mass index (BMI) of 30 kg/m2 or greater. The prevalence is based on 2008 data compiled by the National Behavioral Risk Factor Surveillance System (BRFSS).

Obesity rates continue rise in the United States. While genetic factors can impact a person’s risk of obesity, unhealthy diets and a lack of physical activity play an important role in the rise in obesity rates.xviii Obesity is related to many chronic diseases that affect Pima County residents, including cardiovascular disease, hypertension, and diabetes. The rate of obesity among Pima County adults has increased by nearly four percent according to the average annual prevalence of 20.4 percent from 2001‐2007.xix

49 Adult Leisure‐Time Physical Inactivity

Pima County has one of the lowest rates of adult leisure‐time physical inactivity in Arizona, with 19.7 percent of the adult population not participating in any physical activities or exercises such as running, calisthenics, golf, gardening or walking for exercise in the past month.xx According to the World Health Organization, physical inactivity is the fourth leading risk factor for global mortality. Regular moderate physical activity can reduce the risk of cardiovascular disease, diabetes, colon and breast cancer as well as depression.xxi

Figure 22: 2008 Age‐Adjusted Estimates of the Percentage of Adults Who Are Physically Inactive in Arizona

(Source: Department of Health and Human Services, Centers for Disease Control and Prevention. County‐Level Estimates of Leisure‐Time Physical Inactivity: State Maps. Retrieved March 13, 2012 from http://apps.nccd.cdc.gov/DDT_STRS2/CountyPrevalenceData.aspx?StateId=4& mode=PHY)

50 Screenings Utilization Rates – Diabetes and Mammography Screening

Table 15: Diabetes and Mammography Screening Rates ‐ Pima County

DIABETES AND MAMMOGRAPHY SCREENING

Error Pima Margin + or County – 3% National Benchmark* Arizona

Diabetic screening** 79% 75‐83 89% 76%

Mammography 69.7 66‐73 74% 64% screening***

*The national benchmark is the point at which only 10% of counties in the nation do better, i.e., the 90th or 10th percentile, depending on whether the measure is framed positively or negatively. (From "2011 Pima County, AZ" County Health Rankings, http://www.countyhealthrankings.org/arizona/pima.) **Based on the number of diabetic Medicare enrollees, 2006‐2007. ***Based on the number of female Medicare enrollees, 2006‐2007.

DEFINITIONS:

 “Diabetic screening is calculated as the percent of diabetic Medicare patients whose blood sugar control was screened in the past year using a test of their glycated hemoglobin (HbA1c) levels.”xviii  “Mammography screening represents the percent of female Medicare enrollees age 67‐69 that had at least one mammogram over a two‐year period.”xviii

HbA1c testing is an important part of a comprehensive diabetes management plan and is a key part of a diabetic patient’s disease monitoring practices. Diabetes is also related to other health conditions including heart disease, obesity, hypertension and renal failure. However, the HbA1c test does not account for those who go undiagnosed with diabetes and therefore do not receive the test as part of their follow‐up care. Further, the measurement is limited to Medicare patients, the majority of whom are people aged 65 years and older, so younger populations are underrepresented in this data.xviii While Pima County was among the top five

51 counties in terms of percent of population that were screened and had a higher percent screened than the state of Arizona, the county still fell short of the national benchmark of 89 percent.

Mammography screening has been shown to reduce cancer mortality by 15 to 35 percent, depending on the study referenced.xviii While American Cancer Society guidelines recommend women receive annual mammograms beginning at age 40, there has been much discussion regarding whether the benefits of mammography screening outweigh the risks.xviii Still, mammography screening is currently the best available tool to detect cancer early when treatment is most effective.xxii Similar to the diabetic screening measurement, the mammography screening measurement only takes into account the percent of female Medicare enrollees age 67 to 69 that had at least one mammogram over a two‐year period – meaning that younger populations that are also at risk of breast cancer are not included. Compared to the rest of the state, Pima County had the highest rate of 67‐ to 69‐year‐olds screened, yet still fell short of the national benchmark of 74 percent.

V. MATERNAL AND CHILD HEALTH Infant Mortality Rate

The infant mortality rate is the number of infant deaths, less than 1 year old, per 1,000 live births. Over the past five years, Pima County has seen an overall decrease in the infant mortality rate, which stood at 6.1 deaths/1,000 live births. This rate is slightly higher than the overall Arizona rate of 6.0/1000, and is the sixth lowest rate among all 15 Arizona counties.

Table 16: Infant Mortality Rates by County of Residence, Arizona and United States, 2000‐2010

INFANT MORTALITY RATES1 BY COUNTY OF RESIDENCE, ARIZONA AND UNITED STATES, 2000‐2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

U.S. 6.9 6.9 7.0 6.8 6.8 6.9 6.6 6.7 6.5 6.4 NA

ARIZONA 6.7 6.9 6.3 6.5 6.7 6.8 6.3 6.8 6.3 5.9 6.0

Apache 12.4 7.4 5.4 4.8 9.0 10.9 5.0 5.2 10.7 8.9 6.4

Cochise 6.3 7.3 7.6 10.8 7.2 10.7 9.4 8.6 6.2 5.4 8.4

Coconino 8.6 3.2 7.0 5.7 6.9 6.8 4.8 6.1 5.5 3.2 8.5 Gila 8.9 6.2 11.5 8.7 9.0 10.8 4.5 14.4 4.3 5.7 10.4

52 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Graham 2.2 9.0 12.3 4.6 2.2 6.6 3.7 12.0 9.3 3.1 7.5

Greenlee 0.0 10.5 10.3 0.0 9.8 10.1 0.0 0.0 7.6 0.0 9.5

La Paz 16.3 10.8 4.3 9.3 8.7 4.1 4.4 4.3 12.2 11.5 10.0

Maricopa 6.5 6.7 6.4 6.3 6.5 6.2 6.1 6.4 6.1 5.7 5.8

Mohave 9.0 6.6 4.5 9.8 7.3 12.1 7.3 7.0 3.5 5.4 5.4

Navajo 6.5 6.4 4.3 8.7 6.7 8.9 4.8 10.9 8.7 4.8 5.2

Pima 6.1 7.6 7.2 6.6 7.6 8.4 7.2 7.2 7.2 6.3 6.1

Pinal 9.6 8.2 5.9 6.5 6.5 8.2 6.5 7.4 5.8 7.3 4.0

Santa 3.8 2.6 5.2 1.3 8.7 5.1 5.3 6.5 5.0 5.3 15.9 Cruz

Yavapai 6.8 8.0 4.7 4.3 3.0 4.7 8.0 7.9 4.1 7.3 5.5

Yuma 5.3 8.3 2.6 7.2 5.1 4.3 5.4 7.4 7.7 6.2 6.2 1The number of infant deaths per 1,000 live births. The U.S. rates for 2007-2010 are provisional. Source: (“Table 5E‐18: Infant Mortality by County of Residence, Child’s Race/Ethnicity and Gender, Arizona, 2010,” Arizona Health Status and Vital Statistics 2010 ADHS – http://azdhs.gov/plan/report/ahs/ahs2010/5e.htm)

However, there is a significant disparity in infant mortality rates among the various Primary Care Areas (PCAs) that comprise Pima County, with rates of infant mortality among the following PCAs higher than that of Pima County: Tanque Verde, Tohono O’Odham Nation, Tucson Central, Tucson East Central, Tucson East, Tucson North Central, Tucson Southeast and Tucson Southwest. The rate is not calculated in PCAs in which the total number of deaths is less than 30; therefore, 2010 data was not included for the following PCAs: Ajo, Arivaca, Catalina, Continental, Green Valley, Marana, Pascua Yaqui and Tucson West.

53 Table 17: Infant Mortality Rate per 1000 Live Births by Selected Primary Care Area

Infant Mortality Primary Care Area Rate/1,000 Live (PCA) Births* Tanque Verde 6.9 Tohono O'odham Nation 16 Tucson Central 7.7 Tucson East Central 7 Tucson East 8.9 Tucson North Central 8.6 Tucson Northeast 5.6 Tucson Northwest 5 Tucson Southeast 7.6 Tucson Southwest 8.1 *Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 23: Infant Mortality per 1,000 Live Births by Primary Care Area ‐ Pima County

Low Birth Weight Statistics Figure 24: Infant Mortality per 1,000 Live Births by Primary Care Area ‐ Greater Tucson

55 Low‐birth weight is defined as the number of live births weighing 2,500 grams (5 lbs, 8 oz.) or less, per 1,000 live births. In 2010, Pima County was at an 11‐year low in terms of number of low‐weight births

Table 18: Low‐Birth weight Births by County of Residence, Arizona, 2000‐2010

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ARIZONA* 5,975 5,943 5,926 6,427 6,704 6,640 7,266 7,285 7,026 6,573 6,155

Apache 84 80 57 84 102 101 80 69 89 91 75

Cochise 114 126 117 131 128 144 171 140 141 152 142

Coconino 125 155 137 161 175 173 175 158 155 154 131

Gila 46 37 48 59 55 52 59 61 72 55 59

Graham 28 31 38 19 36 31 46 48 62 46 27

Greenlee 5 8 5 6 8 7 5 13 9 7 10

Maricopa 3,711 3,849 3,799 4,110 4,271 4,253 4,638 4,662 4,370 4,113 3,851

Mohave 125 107 134 145 146 133 155 180 141 136 141

Navajo 142 127 118 134 150 149 152 152 160 148 154

Pima 1,021 873 922 970 969 907 1,047 978 1,024 895 853

Pinal 195 185 209 195 224 285 298 346 358 352 330

Santa Cruz 51 50 48 60 78 50 52 49 61 73 58

Yavapai 130 123 130 132 141 154 171 189 146 154 115

Yuma 173 174 149 204 202 185 195 219 222 188 204

La Paz 13 13 12 9 11 9 14 21 16 9 5

Includes records with unknown county of residence. Source: “Table 5B‐16: Low‐Birth Weight Births by County of Residence, Arizona, 2000‐2010,” Arizona Health Status and Vital Statistics 2010, ADHS – http://azdhs.gov/plan/report/ahs/ahs2010/5b.htm.

56 The highest number of low‐birth weight births in Pima County occurred among mothers of White non‐Hispanic, and Hispanic or Latino ethnicities, with 308 and 385 low‐weight births occurring among these populations, respectively:

Table 19: Low Birth weight Births by Mother's Race/Ethnicity and County of Residence, Arizona, 2010

Mother’s race/ethnicity Black or American Total White non Hispanic Asian or Pacific African Indian or Unknown Hispanic or Latino Islander American Alaska Native ARIZONA 6,155 2,579 2,342 492 406 280 56

Apache 75 14 1 0 60 0 0

Cochise 142 56 64 7 0 12 3

Coconino 131 59 30 2 39 1 0

Gila 59 26 10 0 22 0 1

Graham 27 17 5 0 5 0 0

Greenlee 10 6 4 0 0 0 0

Maricopa 3,851 1,617 1,494 397 107 206 30

Mohave 141 115 14 2 2 5 3

Navajo 154 48 10 0 90 5 0

Pima 853 308 385 59 46 40 12

Pinal 330 177 97 20 28 7 1

Santa Cruz 58 0 58 0 0 0 0

Yavapai 115 84 22 2 3 3 1

Yuma 204 50 145 3 4 1 1

La Paz 5 2 3 0 0 0 0 Source: “Table 5B‐16: Low‐Birth Weight Births by Mother’s Race/Ethnicity and County of Residence, Arizona, 2010,” Arizona Health Status and Vital Statistics 2010, ADHS – http://azdhs.gov/plan/report/ahs/ahs2010/5b.htm.

Figure 25: Low‐Weight Births per 1,000 Live Births by Primary Care Area ‐ Pima County

Figure 26: Low‐Weight Births per 1,000 Live Births by Primary Care Area ‐ Greater Tucson

*Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

58 Women Who Receive Late or No Prenatal Care

Prenatal care is considered “late” if it began in the 2nd or 3rd trimester of pregnancy. In 2010, more than three‐quarters (75.3 percent) of Pima County women received prenatal care in their first trimester, and less than two percent received no care at all. 22.9 percent of women received late prenatal care.

Table 20: Births by Trimester of Pregnancy Prenatal Care Began and Mother's County of Residence, Arizona, 2010

1st Total No care 2nd trimester 3rd trimester Unknown trimester Count % Count % Count % Count % Count % Count % ARIZONA 87,053 100.0 1,382 1.6 71,331 81.9 11,377 13.1 2,812 3.2 151 0.2

Apache 1,099 100.0 21 1.9 685 62.3 286 26.0 103 9.4 4 0.4

Cochise 1,781 100.0 56 3.1 1,404 78.8 263 14.8 52 2.9 6 0.3

Coconino 1,775 100.0 22 1.2 1,499 84.5 201 11.3 48 2.7 5 0.3

Gila 670 100.0 12 1.8 445 66.4 177 26.4 36 5.4 0 0.0

Graham 530 100.0 5 0.9 395 74.5 114 21.5 16 3.0 0 0.0

Greenlee 105 100.0 0 0.0 75 71.4 18 17.1 12 11.4 0 0.0

Maricopa 54,236 100.0 686 1.3 46,567 85.9 5,636 10.4 1,231 2.3 116 0.2

Mohave 2,022 100.0 26 1.3 1,555 76.9 288 14.2 148 7.3 5 0.2

Navajo 1,737 100.0 35 2.0 1,180 67.9 402 23.1 116 6.7 4 0.2

Pima 12,169 100.0 215 1.8 9,164 75.3 2,251 18.5 532 4.4 7 0.1

Pinal 4,990 100.0 80 1.6 4,317 86.5 497 10.0 95 1.9 1 0.0 Santa 693 100.0 19 2.7 483 69.7 137 19.8 54 7.8 0 0.0 Cruz Yavapai 1,817 100.0 17 0.9 1,436 79.0 303 16.7 59 3.2 2 0.1

Yuma 3,229 100.0 181 5.6 1,986 61.5 762 23.6 300 9.3 0 0.0

La Paz 200 100.0 7 3.5 140 70.0 42 21.0 10 5.0 1 0.5 Source: “Table 5B‐11: Births by Trimester of Pregnancy Prenatal Care Began and Mother’s County of Residence, Arizona, 2010,” Arizona Health Status and Vital Statistics 2010, ADHS ‐ http://azdhs.gov/plan/report/ahs/ahs2010/5b.htm.

59 Table 21: Average Number of Prenatal Visits During Pregnancy According to Selected Characteristics of Newborns and Mothers Giving Birth by County of Residence, Arizona, 2010

Newborn Length of Weight at Marital status Payee for births Mother’s race/ethnicity intensive gestation birth care

‐

Total

Indian

Native

Pacific non African

grams grams

weeks

weeks weeks insurance No

or IHS Yes Self or

Other 41 Latino ‐ AHCCCS Married Islander Hispanic American <37 42+ Alaska Unmarried White Hispanic

37 <2,500 2,500+ Asian Black or American

Private AZ 11.0 12.0 10.0 11.0 10.0 9.0 12.0 11.0 12.0 10.0 11.0 10.0 12.0 10.0 12.0 12.0 10.0 12.0 10.0 12.0

Pima 11.0 11.0 11.0 11.0 11.0 10.0 12.0 10.0 11.0 11.0 10.0 10.0 11.0 9.0 11.0 12.5 10.0 11.0 10.0 11.0 * The arithmetic mean value for the number of prenatal visits in specified group. Excluded are cases with no prenatal care and/or unspecified number of prenatal visits. The Arizona Health Care Cost Containment System (AHCCCS) is the State's Medicaid program. Data compiled from “Table 5B: Births by Mother’s Race/Ethnicity, the Party Paying for the Delivery and County of Residence, Arizona, 2010,” Arizona Health Status and Vital Statistics 2010, ADHS ‐ http://azdhs.gov/plan/report/ahs/ahs2010/5b.htm.

As shown in in the figure above, in Pima County in 2010, prenatal care visits averaged 11 for White non‐Hispanic, Hispanic or Latino, and Asian or Pacific Islander mothers compared to 10 visits for Black or African American and American Indian or Alaska Native mothers.

Early (first‐trimester) rates of prenatal care that were higher than the overall Pima County rate were seen in the Arivaca, Tanque Verde, Tucson Northeast and Tucson Northwest PCAs. Ajo, Pascua Yaqui, Tohono O’Odham Nation and Tucson Southeast had the lowest rates of first‐trimester prenatal care among the county’s PCAs.

60 Table 22: Percent of Pregnant Women Who Receive Prenatal Care During 1st Trimester by Primary Care Area ‐ Pima County

Percent 1st Primary Care Area* Trimester Prenatal Care

Ajo 63.3 Arivaca 75.5 Catalina 72.6 Continental 74.1 Green Valley 70 Marana 70.3 Pascua Yaqui 66.6 Tanque Verde 77.9 Tohono O'odham Nation 62.7 Tucson Central 65 Tucson East Central 72 Tucson East 67.6 Tucson North Central 68 Tucson Northeast 76.9 Tucson Northwest 80 Tucson Southeast 62.7 Tucson Southwest 69.4 Tucson West 71.4

*Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 27: Prenatal Care Beginning in the First Trimester by Primary Care Area ‐ Pima County

Figure 28: Prenatal Care Beginning in the First Trimester by Primary Care Area ‐ Greater Tucson

62 Teen Pregnancy and Birth Rate

The Arizona Department of Health Services provides trend data for teen pregnancies according to the following age groups: 10‐17 years, 18‐19 years and 19 years and younger. Overall, from 1999‐2009 (the most recent published data), Pima County saw a significant decline in the number of teen pregnancies per 1,000 females in each of these age groups. From 1999 to 2009, the number of teen pregnancies per 1,000 females dropped from 38.8 to 27.0 in the 19 years and younger age group; from 118.3 to 82.3 in the 18‐19 years age group and from 17.6 to 11.2 in the 10‐17 years age group. Pima County fell below the overall state rate in both the 19 years or younger and the 18‐19 years age group, and matched the state rate of 11.2 pregnancies for 10‐17 year olds. Table 23: Trends in Pregnancy Rates by County of Residence Among Females 10‐17 and 18‐19 Years, Arizona, 1999‐2009

Source: “Table 9: Trends in pregnancy rates by county of residence among females 10‐ 17 and 18‐19 years, Arizona, 1999‐2009,” Arizona Health Status and Vital Statistics 2009, ADHS ‐ http://www.azdhs.gov/plan/report/tp/teen09/index.htm.

PCA Statistical Profiles provide teen birth rates per 1,000 females aged 14‐19 years. According to the statistical profiles, the county rate is 51 per 1,000 and the state rate is 55.1 per 1,000 for this age group. PCAs that have higher rates of teen births per 1,000 females than the county rate are Ajo, Continental, Tanque Verde, Tohono O’odham Nation, Tucson East, Tucson North Central, Tucson Southeast, Tucson Southwest and Tucson West.

Table 24: Teen Births 14‐19 Years per 1,000 Females by Primary Care Area ‐ Pima County

Teen Births 14‐19 Primary Care Area years/1,000 females Ajo 84.1 Arivaca 35.6 Catalina 42.7 Continental 79.9 Green Valley No data Marana 46.5 Pascua Yaqui 157.4 Tanque Verde 31.3 Tohono O'odham Nation 66.5 Tucson Central 31.9 Tucson East Central 49.4 Tucson East 53.1 Tucson North Central 61.6 Tucson Northeast 17.6 Tucson Northwest 20.9 Tucson Southeast 95 Tucson Southwest 87.8 Tucson West 74.6

Data compiled from Arizona Primary Care Area Program 2010 Statistical Profiles, Arizona Department of Health Services. Retrieved on March 6, 2012 from http://www.azdhs.gov/hsd/profiles/index.htm.

Figure 29: Teen Births per 1,000 Females Age 14‐19 by Primary Care Area ‐ Pima County

Figure 30: Teen Births per 1,000 Females age 14‐19 by Primary Care Area ‐ Greater Tucson

65 At the time this report was written, the ADHS had published 2010 data for births by mother’s age group, race/ethnicity and county of residence. While the age groups differ from those in the previous figure, among the total number of births for 18‐ to 19‐year‐olds in Pima County in 2010 (923), 236 were to White non‐Hispanic mothers, 550 were to Hispanic or Latino mothers, 58 were to Black or African American mothers, 64 were to American Indian or Alaska Native mothers and 2 were to Asian or Pacific Islander mothers.

Table 25: Births by Mother's Age Group, Race/Ethnicity and County of Residence, Arizona, 2010

Mother’s age group Total 15‐ 18‐ 35‐ 40‐ Un‐ <15 20‐24 25‐29 30‐34 45+ 17 19 39 44 known ARIZONA Total 87,053 105 2,910 6,401 22,216 24,900 19,299 9,115 1,939 156 12 White non‐ 38,777 12 541 1,833 8,402 12,315 10,006 4,595 969 102 2 Hispanic Hispanic or Latino 34,333 68 1,859 3,421 9,952 8,921 6,380 3,071 636 24 1 Black or African 4,328 10 151 401 1,353 1,187 761 375 84 6 0 American American Indian or 5,815 14 331 643 1,998 1,429 876 427 91 6 0 Alaska Native Asian or Pacific 3,293 1 23 79 420 928 1,154 562 123 3 0 Islander Other/unknown 507 0 5 24 91 120 122 85 36 15 9 Pima Total 12,169 14 409 923 3,109 3,500 2,699 1,227 268 19 1 White non‐ 5,049 1 62 236 1,082 1,596 1,346 586 127 12 1 Hispanic Hispanic or Latino 5,459 11 290 550 1,580 1,462 1,003 459 98 6 0 Black or African 548 1 13 58 175 164 79 48 10 0 0 American American Indian or 553 1 41 64 181 132 83 44 6 1 0 Alaska Native Asian or Pacific 457 0 2 11 78 128 153 66 19 0 0 Islander Other/unknown 103 0 1 4 13 18 35 24 8 0 0 Source: “Table 5B‐10: Births by Mother’s Age Group, Race/Ethnicity and County of Residence, Arizona, 2010,” Arizona Health Status and Vital Statistics 2010, ADHS ‐ http://www.azdhs.gov/plan/report/ahs/ahs2010/5b.htm).

66 HEALTHY PEOPLE 2020: MATERNAL, INFANT AND CHILD HEALTH BENCHMARKS:

The Arizona Health Matters website reports on whether counties meet population health goals set forth by the federal government’s Healthy People 2020 program. U.S. Healthy People 2020 is a comprehensive set of key disease prevention and health promotion objectives. The following indicators show how Pima County is faring in the Maternal, Infant and Child Health benchmarks set forth by Healthy People 2020. (NOTE: The Arizona Department of Health Services (AZDHS) updated its vital statistics with 2010 data in February of 2012. The Arizona Health Matters website, which utilizes data from the AZDHS, had not yet been updated with the 2010 AZDHS data at the time this report was written, and is based on 2009 AZDHS data.)

INFANT MORTALITY RATE: Pima County has not yet met its target goal for the mortality rate in deaths per 1,000 live births for infants within their first year of life. The 2009 mortality rate is 6.3 deaths per 1,000 live births; the target goal under Healthy People 2020 is 6.0 deaths per 1,000 live births. However, the rate has been decreasing over time.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Infant mortality rate continues to be one of the most widely used indicators of the overall health status of a community. The leading causes of death among infants are birth defects, pre‐term delivery, low birth weight, Sudden Infant Death Syndrome (SIDS) and maternal complications during pregnancy.”xxiii

MOTHERS WHO RECEIVED EARLY PRENATAL CARE: Pima County has not yet met its target goal for the percentage of births to mothers who began prenatal care in the first trimester of their pregnancy. The 2009 percentage of first‐trimester prenatal care is 71.9 percent; the target goal under Healthy People 2020 is 77.9 percent of pregnant women who receive prenatal care in their first trimester of pregnancy. However, the percentage of women receiving first trimester prenatal care has increased since the previous measurement.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Babies born to mothers who do not receive prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care. Early prenatal care (i.e. care in the first trimester of a pregnancy) allows women and their health care providers to identify and, when possible, treat or correct health problems and health‐compromising behaviors that can be particularly damaging during the initial stages of fetal development. Increasing the number of women who receive prenatal care, and who do so early in their pregnancies, can improve birth outcomes and lower health care costs by reducing the likelihood of complications during pregnancy and childbirth.”xxiv

67 BABIES WITH LOW BIRTHWEIGHT: Pima County has met and exceeded its target goal for the percentage of births in which the newborn weighed less than 2,500 grams (5 pounds, 8 ounces). The 2009 percentage is 7 percent of births that weigh less than 2,500 grams; the Healthy People 2020 target is 7.8 percent.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Babies born with a low birth weight are more likely than babies of normal weight to require specialized medical care, and often must stay in the intensive care unit. Low birth weight is often associated with premature birth. While there have been many medical advances enabling premature infants to survive, there is still risk of infant death or long‐term disability. The most important things an expectant mother can do to prevent prematurity and low birth weight are to take prenatal vitamins, stop smoking, stop drinking alcohol and using drugs and most importantly, get prenatal care.”xxv

PRETERM BIRTHS: Pima County has met and exceeded its target goal for the percentage of births with less than 37 weeks of completed gestation. The 2009 percentage of preterm births is 9.5 percent; the Healthy People 2020 target is 11.4 percent.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “Babies born premature are likely to require specialized medical care, and oftentimes must stay in intensive care nurseries. While there have been many medical advances enabling premature infants to survive, there is still risk of infant death or long‐term disability. The most important things an expectant mother can do to prevent prematurity and low birth weight are to take prenatal vitamins, stop smoking, stop drinking alcohol and using drugs, and get prenatal care.”xxvi

VI. INFECTIOUS DISEASES

Sexually‐Transmitted Infections

In 2010, Pima County had the highest incidence rate of total syphilis cases of all Arizona counties at 16.7 cases per 100,000 population and higher than the state rate of 14.1 cases per 100,000. However, this rate shows a decline by nearly 10 cases per 100,000 population in Pima County since 2008.

Pima County had the third highest incidence rate among counties of chlamydia at 420.5 cases per 100,000 population, slightly above the state rate of 420.2. This rate has increased in Pima County from 367.7 cases per 100,000 in 2008.

68 Pima County had the second highest incidence rate of gonorrhea in 2010 at 44.6 per 100,000 population; this number increased from 36.3 cases per 100,000 in 2009, yet declined from the 2008 rate of 51.3 cases per 100,000 population.

Sexually‐transmitted diseases such as chlamydia and gonorrhea can lead to additional, costly and/or painful health complications, such as pelvic inflammatory disease and infertility among women. Statewide, the chlamydia case rate among women in Arizona between 2005 and 2010 has been about three times higher in females than in males. Further, according to the CDC, almost half of the 19 million estimated new sexually‐transmitted infections each year occur among those between the ages of 15 and 19 years. Regarding race and ethnicity, gonorrhea, chlamydia and syphilis case rates throughout Arizona between 2005 and 2010 were highest among African Americans, followed by American Indians (with the exception of syphilis; rates were higher among Hispanics between 2008‐2009).xxvii

Table 26: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010 Gila Pima Pinal Yuma La Paz Navajo Apache Cochise Arizona Mohave Yavapai Graham Greenlee Coconino Maricopa Disease Santa Cruz Sexually Transmitted Genital 29.0 7.0 19.8 21.6 11.2 5.4 0.0 39.0 29.5 17.5 21.4 24.0 36.2 6.3 5.2 28.6 Herpes Gonorrhea 50.8 36.4 21.3 14.9 14.9 26.9 0.0 0.0 59.8 5.5 33.5 44.6 14.4 10.5 7.6 33.7 Gonococcal 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 PID Resistant 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Gonorrhea Syphilis (primary 3.6 4.2 0.8 0.7 0.0 5.4 11.9 0.0 4.1 0.5 0.9 5.2 1.6 0.0 0.9 0.5 and secondary) Syphilis‐ 14.1 4.2 6.9 2.2 1.9 10.7 11.9 0.0 16.4 3.0 1.9 16.7 5.1 2.1 2.4 11.2 Total

Chlamydia 420.2 644.6 303.0 550.5 235.1 346.6 189.6 107.4 408.2 144.9 559.3 420.5 253.9 297.3 114.1 416.9

Note: Non‐resident cases have been excluded. Only incident cases are reported. Cases are counted by date reported to public health. Rates are per 100,000 population in appropriate county. Source: Table 5F‐2: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010, Arizona Health and Vital Statistics 2010, ADHS ‐ http://www.azdhs.gov/plan/report/ahs/ahs2010/5f.htm.

69 Table 27: Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010

Cruz

Paz

Disease Gila Pima Pinal Yuma La Navajo Apache Cochise Arizona Mohave Yavapai Graham Greenlee Coconino Maricopa Santa Sexually Transmitted Genital 1,701 5 26 29 6 2 0 8 1,126 35 23 235 136 3 11 56 Herpes Gonorrhea 2,998 26 28 20 8 10 0 0 2,281 11 36 437 54 5 16 66 Gonococcal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PID Resistant 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Gonorrhea Syphilis (primary 226 3 1 1 0 2 1 0 155 1 1 51 6 0 2 2 and secondary) Syphilis‐ 865 3 9 3 1 4 1 0 625 6 2 164 19 1 5 22 Total Chlamydia 24,642 461 398 740 126 129 16 22 15,583 290 601 4,122 954 141 243 816 Notes: Non‐resident cases have been excluded. Only incident cases are reported. Cases are counted by date reported to public health. Source: Table 5F‐1: Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010,” Arizona Health Status and Vital Statistics 2010, ADHS ‐ http://www.azdhs.gov/plan/report/ahs/ahs2009/5f.htm.

Table 28: Pima County Historical Data for Selected Sexually‐Transmitted Infections, 2008‐2010

PIMA COUNTY HISTORICAL DATA FOR SELECTED SEXUALLY‐TRANSMITTED INFECTIONS, 2008‐2010

Syphilis (Total) Gonorrhea Chlamydia

Cases Rate Cases Rate Cases Rate 2010 164 16.7 437 44.6 4,122 420.5 2009 244 24 370 36.3 3,833 376.5 2008 265 26.1 520 51.3 3,727 367.7 Rates are based per 100,000 population. Compiled from Tables 5F‐1, Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona; and Table 5F‐2, Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2008, 2009 and 2010, Arizona Health Status and Vital Statistics, ADHS ‐ http://www.azdhs.gov/plan/report/ahs/.

70 HIV/AIDS EMERGENCE AND PREVALENCE

From 2004‐2008, Pima County had the third highest emergence rate of HIV/AIDS in the state, at 10.12 cases per 100,000 population, and in 2008 had the second highest state prevalence rate at 228.36 cases per 100,000 population (NOTE: When referring to HIV/AIDS, the term emergence is a more accurate measure than incidence, because it tracks the earliest report of HIV infection for each person, which can only occur once regardless of whether the disease progresses to AIDS).xxviii

In Pima County, as in the rest of the state, males have much higher emergent and prevalence rates of HIV/AIDS than females. The highest rates are among those aged 45‐49 years; of Black Non‐Hispanic ethnicity; and the highest percentage of transmission occurs among men having sex with men.

Figure 31: County‐Specific Prevalent HIV/AIDS Arizona, 2008

Source: Arizona Department of Health Services, Office of HIV, STD and Hepatitis C Services. HIV/AIDS Integrated Epidemic Profile 2010. Retrieved March 14, 2012 from http://www.azdhs.gov/phs/hiv/pdf/EpidemicProf/integrated_epi_prof_2010.pdf.

Figure 32: County‐Specific Prevalent HIV/AIDS, and State Population, Arizona, 2008

Unmet Need

According to the ADHS HIV/AIDS Integrated Epidemic Profile 2010, “The Unmet Needs Estimate is an annual estimate that measures the proportion of persons living with HIV/AIDS in Arizona who meet a minimal standard of HIV primary care,” which is anything other than having had at least one CD4 count or viral load or having taken HIV medication during the course of the year. In 2009, the percentage of persons with an unmet need for HIV primary care in Pima County was 42 percent, and increase from 37 percent in 2008.

Figure 33: Percentage of Persons with an Unmet Need for HIV Primary Care, 2006‐2009

TUBERCULOSIS

In 2010, Pima County reported a tuberculosis case rate of 1.9 per 100,000 population, lower than the Arizona state case rate of 4.4 per 100,000 and lower than the U.S. rate of 3.6 per 100,000. Pima County reported 6.7 percent of the cases of tuberculosis (19/282), despite having 15.4 percent of the state’s overall population.

Risk factors associated with 2010 Arizona cases of tuberculosis include the following:

 Occupations such as migrant farm workers and health care workers, comprising 3.0 percent and 1.4 percent of the cases in 2010, respectively;  Substance abuse, including alcohol abuse and/or illicit drug use (13.5 percent of 2010 cases);  Correctional facilities (23 percent of 2010 cases);  Homelessness (8.5 percent of 2010 cases);  Country of birth (in 2010, 64.5 percent of Arizona cases occurred in people born outside the U.S. and its territories; and  Co‐infection with HIV (3.5 percent of 2010 cases).

73 In 2010 in Arizona, Hispanic ethnicity accounted for 48.2 percent of the reported TB cases. The mean age for all active TB cases was 43.5 years of age. Males accounted for 66.7 percent of the TB cases.xxix

Table 29: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010

Paz

Gila Cruz Pima Pinal Santa Yuma La Navajo Apache Cochise Arizona Mohave Yavapai Graham Greenlee Coconino Disease Maricopa Tuberculosis Pulmonary 3.6 12.6 1.5 2.2 9.3 8.1 0.0 4.9 2.9 1.0 3.7 1.6 13.0 2.1 0.5 10.7 TB Total TB 4.4 15.4 1.5 4.5 9.3 8.1 0.0 4.9 4.0 1.0 4.7 1.9 13.6 2.1 0.5 11.7 Note: Non‐resident cases have been excluded. Only incident cases are reported. Cases are counted by date reported to public health. Rates are per 100,000 population in appropriate county. Source: Table 5F‐2: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010, Arizona Health and Vital Statistics 2010, ADHS ‐ http://www.azdhs.gov/plan/report/ahs/ahs2010/5f.htm.

Table 30: Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010

Cruz

Paz

Gila Pima Pinal Yuma La Navajo Apache Cochise Arizona Mohave Yavapai Graham Greenlee Coconino Maricopa

Disease Santa Tuberculosis Pulmonary 229 9 2 3 5 3 0 1 112 2 4 16 49 1 1 21 TB Total TB 282 11 2 6 5 3 0 1 152 2 5 19 51 1 1 23 Note: Non‐resident cases have been excluded. Only incident cases are reported. Cases are counted by date reported to public health. Rates are per 100,000 population in appropriate county. Source: Table 5F‐1: Number of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010, Arizona Health and Vital Statistics 2010, ADHS ‐ http://www.azdhs.gov/plan/report/ahs/ahs2010/5f.htm.

Other Reported Infectious Diseases

In the most recent data available (2010), Pima County had the following cases/rates of infectious diseases:

 Vaccine‐Preventable Diseases: One case each of measles and mumps (.1/100,000 population), 10 confirmed cases of pertussis (1/100,000 population) and 0 cases/incidence rate of rubella or Haemophilus influenzae type b (invasive, age < 5 years).

74  Central Nervous System: Pima County had 27 cases of aseptic meningitis (2.8/100,000), three cases of meningococcal disease (.3/100,000) and one case of viral encephalitis (.1/100,000).

 Enterides: Pima County had six cases of amebiasis (.6/100,000, the second highest rate in the state), 140 cases of campylobacteriosis (14.3/100,000), 5 cases of cryptosporidiosis (.5/100,000), 13 cases of E. coli (1.3/100,000), 17 cases of giardiasis (1.7/100,000), 204 cases of salmonellosis (20.8, the fourth highest rate in the state), 4 cases of salmonella paratyphi A (.4/100,000, the highest in the state), 1 case of salmonella paratyphi B (.1/100,000) and 67 cases of shigellosis.

o E. COLI AND SALMONELLA INCIDENCE RATES: Pima County has not yet met its target goals for the incidence rate in cases per 100,000 population for either E. coli or Salmonella. The current rates for E. coli and Salmonella are 1.3 and 20.8 cases per 100,000, respectively. The targets set under Healthy People 2020 are 0.6 and 11.4 cases per 100,000, respectively. The E. coli incidence rate is showing a decrease over time while the Salmonella incidence rate is showing an increase over time.

WHY IS THIS IMPORTANT? The Arizona Health Matters website states, “E. coli bacteria cause disease by making a toxin, or poison. The symptoms of E. coli infections vary for each person but often include severe stomach cramps, diarrhea (often bloody) and vomiting. Most people get better within 5–7 days. Some infections are very mild, but others are severe or even life‐threatening.” “Most persons infected with Salmonella develop diarrhea, fever and abdominal cramps 12 to 72 hours after infection. The illness usually lasts 4 to 7 days, and most persons recover without treatment.”xxx

 Mycosis: Pima County had a Valley Fever rate of 138 per 100,000 population– the third highest in the state.

 Hepatitis: Pima County had rates per 100,000 of .8, 1.6, .1, and .1 of Hepatitis A, Hepatitis B, Hepatitis D and Hepatitis E, respectively. It was the only county to report incidence rates above 0 for Hepatitis D and E.

 Zoonoses/Vectorborne: Pima County had rates per 100,000 of .2, .1, .5, and 1.2 of Brucellosis, Dengue, Malaria and West Nile Virus, respectively. The county’s Malaria rate was slightly higher than the state’s rate of .4/100,000.

 Other: Pima County had rates per 100,000 of 1.0, 18.8, 4.6, .9, 14.8, .2 and .2 of Legionellosis, Listeriosis, Methicillin Resistant S. Aureus, Streptococcal

75 Group A, Streptococcal Group B, Streptococcus pneumonia, Vibrio spp. and Yersiniosis, respectively.

Table 31: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010

Cruz

Paz

Gila Pima Pinal Yuma La Navajo Apache Cochise Arizona Mohave Yavapai Graham Greenlee Coconino Maricopa Disease Santa Vaccine Preventable Measles 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Mumps 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Pertussis 6.4 1.4 4.6 3.0 1.9 13.4 0.0 0.0 7.6 2.0 4.7 4.7 1.6 4.2 15.2 1.5 Pertussis (confirmed only) 1.2 0.0 0.8 0.7 1.9 0.0 0.0 0.0 1.2 1.0 0.0 1.0 0.8 4.2 3.8 0.5 Rubella 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.0 Congenital Rubella Syndrome 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Haemophilus influenzae b (invasive 0.4 0.0 0.0 11.2 0.0 0.0 0.0 0.0 0.0 9.1 0.0 0.0 0.0 0.0 0.0 0.0 disease in children < 5 years old)

Central Nervous System Aseptic Meningitis 9.0 1.4 4.6 3.7 5.6 0.0 0.0 0.0 13.0 3.5 0.9 2.8 4.8 0.0 6.2 0.5 Meningococcal Disease 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.5 0.9 0.3 0.0 2.1 0.5 0.0 Viral Encephalitis ‐ Total 0.1 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.9 0.0 Enteritides Amebiasis 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.6 0.3 8.4 0.5 0.0 Campylobacteriosis 14.7 60.1 24.4 11.9 31.7 16.1 11.9 9.8 14.0 5.0 42.8 14.3 8.8 38.0 5.2 14.3 Cholera 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Cryptosporidiosis 0.6 1.4 0.0 2.2 1.9 0.0 0.0 0.0 0.6 1.0 0.9 0.5 0.3 0.0 0.5 0.0 E. coli O157:H7 1.5 1.4 1.5 1.5 0.0 2.7 0.0 0.0 1.5 0.5 0.9 1.3 2.9 0.0 2.8 0.5 Giardiasis 2.4 5.6 1.5 1.5 5.6 8.1 0.0 0.0 2.6 2.0 1.9 1.7 1.6 0.0 2.8 1.0 Salmonellosis (except S. Typhi and S. 14.3 12.6 19.0 18.6 20.5 29.6 11.9 19.5 12.1 3.0 31.6 20.8 14.9 29.5 12.3 12.3 Paratyphi) Salmonella Paratyphi A 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.4 0.0 0.0 0.0 0.0 Salmonella Paratyphi B 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.3 0.0 0.0 0.0 Salmonella Paratyphi C 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Shigellosis 6.8 35.0 6.1 15.6 7.5 0.0 11.9 4.9 6.2 3.0 16.8 6.8 3.2 21.1 0.0 13.8 Typhoid Fever 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Mycosis Coccidioidomycosis (Valley Fever) 175.9 33.6 35.8 31.2 80.2 61.8 0.0 117.1 234.6 57.4 29.8 138.0 138.1 27.4 18.0 9.7

Hepatitides Hepatitis A 1.1 1.4 2.3 1.5 1.9 0.0 0.0 0.0 1.0 1.5 0.9 0.8 1.3 2.1 0.9 1.0 Hepatitis B (acute) 2.3 4.2 1.5 1.5 1.9 0.0 0.0 4.9 2.4 7.5 1.9 1.6 1.9 2.1 1.4 2.0 Hepatitis B, Perinatal 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Hepatitis C (acute) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Hepatitis D 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Hepatitis E 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Tubercuslosis Pulmonary TB 3.6 12.6 1.5 2.2 9.3 8.1 0.0 4.9 2.9 1.0 3.7 1.6 13.0 2.1 0.5 10.7 Total TB 4.4 15.4 1.5 4.5 9.3 8.1 0.0 4.9 4.0 1.0 4.7 1.9 13.6 2.1 0.5 11.7

Cruz

Paz

Gila Pima Pinal Yuma La Navajo Apache Cochise Arizona Mohave Yavapai Graham Greenlee Coconino Maricopa Disease Santa Zoonoses/Vectorborne Brucellosis 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.2 0.0 0.0 0.0 0.5 Colorado Tick Fever 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.0 Dengue 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.5 0.0 Ehrlichiosis 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Hantavirus Pulmonary Syndrome 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Human Rabies 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Lyme Disease 0.0 0.0 0.8 0.7 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 Malaria 0.4 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.5 0.5 0.0 0.5 0.0 0.0 0.0 0.0 Plague 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Relapsing Fever, Tickborne 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rocky Mtn. Spotted Fever 0.0 0.0 0.0 0.0 1.9 0.0 0.0 0.0 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 St. Louis Encephalitis 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Tularemia 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 West Nile Virus 2.6 1.4 1.5 1.5 16.8 24.2 0.0 0.0 3.0 0.0 0.9 1.2 4.0 0.0 0.0 0.0

Other Legionellosis 1.0 1.4 1.5 0.0 1.9 2.7 0.0 4.9 1.1 0.0 0.9 1.0 0.3 0.0 0.0 0.0 Listeriosis 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.3 0.0 0.0 0.0 0.5 Methicillin Resistant S. aureus 17.6 1.4 16.0 6.7 22.4 21.5 35.6 4.9 20.1 23.0 11.2 18.8 12.0 10.5 1.9 3.1 (invasive) Streptococcal Group A (Invasive) 2.8 5.6 4.6 2.2 0.0 0.0 0.0 0.0 2.5 2.0 10.2 4.6 1.6 2.1 0.5 1.0 Streptococcal Group B (Invasive 0.7 0.0 0.8 0.0 0.0 0.0 0.0 4.9 0.8 0.5 0.0 0.9 0.0 2.1 0.0 1.0 disease in infants<90 days old) Streptococcus pneumoniae (invasive) 11.9 30.8 12.9 10.4 16.8 24.2 23.7 4.9 10.3 15.5 29.8 14.8 8.8 8.4 14.7 7.2 Reyes Syndrome 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Toxic Shock Syndrome 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Botulism 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Vibrio spp. (except toxogenic V. 0.3 0.0 0.0 0.0 0.0 0.0 11.9 0.0 0.4 0.0 0.0 0.2 0.0 0.0 0.0 1.0 cholerae) Yersiniosis (except Y. pestis) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0

Notes: Non‐resident cases have been excluded. Only incident cases are reported. Cases are counted by date reported to public health. Case counts include both probable and confirmed cases unless otherwise indicated. E. coli has included both E. coli O157:H7 and Shiga‐toxin positive E. colis since October 2004. Haemophilus influenzae type b includes all invasive H. influenzae type b, not just meningitis, as of 1995. Meningococcal includes all invasive disease caused by Neisseria meningitidis, not just meningitis. Animal Rabies cases are not included. Hepatitis E has been reported separately from Hepatitis non‐A non‐B beginning in 1998. Rates calculated for Streptococcus‐Group B (invasive disease in infants <90 days old) represent the number of cases per 1,000 live births; all other morbidities are per 100,000 Arizona residents in appropriate county. West Nile Virus cases are counted by patient onset date.

Note: In mid‐2009, a large laboratory changed its reporting practices for coccidioidomycosis. Reported coccidioidomycosis has been elevated since then.

Note: Non‐resident cases have been excluded. Cases with unknown county of residence are included in the Arizona total.

Table includes all positive laboratory results for chlamydia and gonorrhea with or without disease report in 2010. Source: Arizona Department of Health Services, Bureau of Epidemiology and Disease Control Services, Office of Infectious Disease Services. Table 5F‐2: Rates of Reported Cases of Selected Notifiable Diseases by Category for Each County, Arizona, 2010, Arizona Health Status and Vital Statistics 2010. Retrieved March 14, 2012 from http://www.azdhs.gov/plan/report/ahs/ahs2010/5f.htm.

77 VII. NATURAL AND BUILT ENVIRONMENT

Air Quality Ratings

The Centers for Disease Control and Prevention and the EPA have collected data through the Public Health Air Surveillance Evaluation (PHASE) Project to measure air quality. Air pollution, such as exposure to excess levels of ozone of high levels of particulate matter, is associated with decreased lung function, bronchitis, asthma and other respiratory conditions.xxxi The most recent data available is from 2006, which indicates that Pima County has a better air quality rating than the state rating. NOTE: More recent data, collected by the American Lung Association and available through the Arizona Health Matters website, shows that Pima County has a grade of “C” on an A‐F scale for Annual Ozone Air Quality.

Table 32: Air Quality ‐ Pima County

Air Quality

Error National Pima County Arizona Margin Benchmark*

Air pollution ‐ 0 0 1 particulate matter days

Air pollution ‐ 9 0 29 ozone days

DEFINITIONS:

 Air pollution – particulate matter days represents the annual number of days that air quality was unhealthy for sensitive populations due to fine particulate matter.

 Air pollution – ozone days measures the annual number of days that air quality was unhealthy for sensitive populations due to ozone levels.

78 Pima County has the fourth highest number of ozone days in the state. According to Arizona Health Matters, “Ozone is an extremely reactive gas…Ozone essentially attacks lung tissue by reacting chemically with it.”xxxii

Access to Healthy Foods and Recreational Facilities

While Pima County residents have better access to healthy foods and recreational facilities than most Arizonans, Pima still falls far below the national benchmarks for both access to healthy foods (81 percent compared to the national benchmark of 92 percent) and access to recreational facilities (10 compared to the national benchmark of 17).

Table 33: Access to Healthy Foods and Recreational Facilities ‐ Pima County

Access To Healthy Foods and Recreational Facilities

Error National Pima County Arizona Margin Benchmark*

Access to healthy foods 81% 92 72%

Access to recreational 10 17 8 facilities

DEFINITIONS:

 Access to healthy foods is based on the percent of zip codes in a county with a grocery store or produce stand/farmers market, which are defined as healthy food outlets according to the North American Industrial Classification System (NAICS).  Access to recreational facilities represents the number of recreational facilities (establishments primarily engaged in fitness/conditioning and physical activity) per 100,000 population in a given county.

Access to healthy foods – specifically, grocery stores or produce stands where fresh fruits and vegetables as well as low‐fat, high fiber foods are available – is often poor

79 in low‐income, minority neighborhoods. The lack of access to healthy foods has also been associated with higher prevalence of obesity.

While various socioeconomic factors, as well as urban/rural status and weather patterns can impact a population’s tendency to utilize recreational facilities, the data collected to address access to recreational facilities is not reliable in determining the overall usage by community members. The data does not measure natural fitness activities, such as parks.xxxiii

VIII. SOCIAL ENVIRONMENT

Violent Crime – Homicide Rate

Pima County ranks slightly lower than Arizona in terms of homicide rate, but significantly higher than the national benchmark. Pima County was among the top seven counties in terms of homicide rate during the measurement period (2001‐ 2007).

Table 34: Homicide Rate ‐ Pima County

Pima National Error Margin Arizona County Benchmark*

Homicide Rate 8.00 8 to 9 1 9.00

DEFINITIONS:

 Homicide is the crude death rate per 100,000 population due to murder or non‐negligent manslaughter. The data was collected by the National Center for Health Statistics using a seven‐year period to create more robust estimates of cause‐specific mortality. Homicide rate is used as a proxy for violent crime in this ranking methodology.xxxiv

80 Housing Affordability

The most recent report of Arizona Health Matters indicates that 41.4 percent of Pima County renters spend 30 percent or more of their household income on rent. According to this data, Pima County has the second highest percentage of this indicator in the state. Unfortunately, this indicator is based on 2000 Census data and has not yet been updated with 2010 data. However, more recent data indicated that nearly half (47.9 percent) of households that pay rent in Pima County are cost‐burdened (paying more than 30 percent of the income on housing)xxxv.

IX. RESOURCES/ASSETS

As the second most populous county in Arizona, Pima County is host to more than 300 health service providers available to meet the needs of the community, including hospitals, home health agencies, hospice care, urgent care facilities, pharmacies, Federally Qualified Health Centers, clinics, rehabilitation services, behavioral health services, assisted living facilities and many more. A full list of licensed service providers is available through the Arizona Department of Health Services Provider & Facility Database, accessible at http://azdhs.gov/als/databases/index.htm.

The Pima County Health Department also provides information regarding health services and screenings through its local clinic and office locations. A full list of locations and services provided is available through the Pima County Health Department, accessible at http://www.pimahealth.org/clinics_locations.asp.

For the purposes of this assessment, an abbreviated list of Pima County hospitals and Federally Qualified Health Centers is provided below.

Table 35: List of Hospitals and Federally Qualified Health Centers ‐ Pima County

Type Sub‐type Name Address Phone THE UNIVERSITY Of ARIZONA MEDICAL 1501 NORTH TRANSPLANT HOSPITAL CENTER AT THE CAMPBELL AVENUE, (520) 694‐7367 HOSPITAL ARIZONA HEALTH TUCSON, AZ 85724 SCENCE CENTER

355 NORTH WILMOT HOSPITAL LONG‐TERM KINDRED HOSPITAL ROAD, TUCSON, AZ (520) 584‐4500 85711

CARONDELET 4888 NORTH STONE HEART AND HOSPITAL SHORT‐TERM AVENUE, TUCSON, AZ (520) 696‐2328 VASCULAR 85704 INSTITUTE

Type Sub‐type Name Address Phone

6200 NORTH LA NORTHWEST HOSPITAL SHORT‐TERM CHOLLA BOULEVARD, (520) 742‐9000 MEDICAL CENTER TUCSON, AZ 85741

1551 EAST TANGERINE ORO VALLEY HOSPITAL SHORT‐TERM ROAD, ORO VALLEY, AZ (520) 901‐3500 HOSPITAL 85755

1601 WEST ST MARY'S CARONDELET ST HOSPITAL SHORT‐TERM ROAD, TUCSON, AZ (520) 872‐3000 MARYS HOSPITAL 85745

350 NORTH WILMOT CARONDELET ST HOSPITAL SHORT‐TERM ROAD, TUCSON, AZ (520) 873‐3000 JOSEPHS HOSPITAL 85711

THE UNIVERSITY OF ARIZONA MEDICAL 1501 NORTH HOSPITAL SHORT‐TERM CENTER‐ CAMPBELL AVENUE, (520) 694‐0111 UNIVERSITY TUCSON, AZ 85724 CAMPUS

5301 EAST GRANT TUCSON MEDICAL HOSPITAL SHORT‐TERM ROAD, TUCSON, AZ (520) 327‐5461 CENTER 85712

The UNIVERSITY OF ARIZONA MEDICAL 2800 EAST AJO WAY, HOSPITAL SHORT‐TERM (520) 294‐4471 CENTER‐ SOUTH TUCSON,AZ 85713 CAMPUS

FEDERALLY FEDERALLY THREE POINTS 15921 WEST AJO WAY, QUALIFIED HEALTH QUALIFIED HEALTH (520) 407‐5700 CLINIC TUCSON, AZ 85735 CENTER CENTER

1701 WEST SAINT FEDERALLY FEDERALLY EL RIO SPECIAL MARYS ROAD, SUITE QUALIFIED HEALTH QUALIFIED HEALTH IMMUNOLOGY (520) 741‐8818 140, 160, TUCSON, AZ CENTER CENTER CLINIC 85745

EL RIO SANTA CRUZ FEDERALLY FEDERALLY 839 WEST CONGRESS NEIGHBORHOOD QUALIFIED HEALTH QUALIFIED HEALTH STREET, TUCS ON, AZ (520) 792‐9890 HEALTH CENTER, CENTER CENTER 85745 INC

FEDERALLY FEDERALLY 350 WEST SAHUARITA SAHUARITA QUALIFIED HEALTH QUALIFIED HEALTH ROAD, SAHUARITA, AZ (520) 625‐3502 WELLNESS CENTER CENTER CENTER 85629

82 Type Sub‐type Name Address Phone

FEDERALLY FEDERALLY 101 WEST IRVINGTON, EL PUEBLO HEALTH QUALIFIED HEALTH QUALIFIED HEALTH SUITE 10, TUCSON, AZ (520) 792‐9890 CENTER CENTER CENTER 85714

FEDERALLY FEDERALLY DESERT SENITA 410 MALACATE QUALIFIED HEALTH QUALIFIED HEALTH COMMUNITY (520) 387‐5651 STREET, AJO, AZ 85321 CENTER CENTER HEALTH CENTER

FEDERALLY FEDERALLY 17388 WEST 3RD QUALIFIED HEALTH QUALIFIED HEALTH ARIVACA CLINIC STREET, ARIVACA, AZ (520) 407‐5500 CENTER CENTER 85601

FEDERALLY FEDERALLY 13395 NORTH MARANA HEALTH QUALIFIED HEALTH QUALIFIED HEALTH MARANA MAIN, (520) 682‐4111 CENTER, INC CENTER CENTER MARANA, AZ 85653

FEDERALLY FEDERALLY 1500 WEST EL RIO SOUTHWEST QUALIFIED HEALTH QUALIFIED HEALTH COMMERCE COURT, (520) 746‐8888 HEALTH CENTER CENTER CENTER TUCSON, AZ 85746

1260 SOUTH FEDERALLY FEDERALLY CONTINENTAL CAMPBELL AVENUE, QUALIFIED HEALTH QUALIFIED HEALTH FAMILY MEDICAL (520) 625‐8504 GREEN VALLEY, AZ CENTER CENTER CENTER 85614

FEDERALLY FEDERALLY BIRTH AND 5979 EAST GRANT QUALIFIED HEALTH QUALIFIED HEALTH WOMEN'S HEALTH ROAD, SUITE 107, (520) 795‐9934 CENTER CENTER CENTER TUCSON, AZ 85712

FEDERALLY FEDERALLY 1101 EAST EL RIO BROADWAY QUALIFIED HEALTH QUALIFIED HEALTH BROADWAY, TUCSON, (520) 792‐3293 CLINIC CENTER CENTER AZ 85719

FEDERALLY FEDERALLY EL RIO HEALTH 1900 EAST SUMMIT QUALIFIED HEALTH QUALIFIED HEALTH CENTER‐SUMMIT STREET, TUCSON, AZ (520) 545‐3860 CENTER CENTER ELEMENTARY 85706

FEDERALLY FEDERALLY KEELING HEALTH 435 EAST GLENN, QUALIFIED HEALTH QUALIFIED HEALTH (520) 682‐3777 CENTER TUCSON, AZ 85705 CENTER CENTER

ALTAR VALLEY FEDERALLY FEDERALLY 9875 SOUTH SASABE HEALTH & QUALIFIED HEALTH QUALIFIED HEALTH ROAD, TUCSON, AZ (520) 822‐9418 WELLNESS CENTER CENTER CENTER 85736 ‐ ROBLES ELE

Type Sub‐type Name Address Phone

FEDERALLY FEDERALLY EL RIO OB/GYN 225 WEST IRVINGTON, QUALIFIED HEALTH QUALIFIED HEALTH (520) 792‐9890 ASSOCIATES TUCSON, AZ 85714 CENTER CENTER

FEDERALLY FEDERALLY 15631 NORTH ORACLE SANTA CATALINA QUALIFIED HEALTH QUALIFIED HEALTH ROAD, SUITE 141, (520) 825‐6763 HEALTH CENTER CENTER CENTER TUCSON, AZ 85739

FEDERALLY FEDERALLY 1150 WHITEHOUSE CONTINENTAL QUALIFIED HEALTH QUALIFIED HEALTH CANYON ROAD, GREEN (520) 625‐4401 PEDIATRICS CENTER CENTER VALLEY, AZ 85614

FEDERALLY FEDERALLY 320 WEST PRINCE EL RIO NORTHWEST QUALIFIED HEALTH QUALIFIED HEALTH ROAD, TUCSON, AZ (520) 792‐9890 HEALTH CENTER CENTER CENTER 85705

FEDERALLY FEDERALLY 12635 WEST RUDASILL ORTIZ COMMUNITY QUALIFIED HEALTH QUALIFIED HEALTH ROAD, TUCSON, AZ (520) 682‐3777 HEALTH CENTER CENTER CENTER 85743

ALTAR VALLEY FEDERALLY FEDERALLY HEALTH & 16350 WEST AJO WAY, QUALIFIED HEALTH QUALIFIED HEALTH (520) 822‐9343 WELLNESS CENTER‐ TUCSON, AZ 85736 CENTER CENTER MIDDLESCHOOL

FEDERALLY FEDERALLY 5000 EAST 29TH FREEDOM PARK QUALIFIED HEALTH QUALIFIED HEALTH STREET, TUCSON, AZ (520) 790‐8500 HEALTH CENTER CENTER CENTER 85711

UNITED 275 WEST FEDERALLY FEDERALLY COMMUNITY CONTINENTAL ROAD, QUALIFIED HEALTH QUALIFIED HEALTH (520) 407‐5604 HEALTH CENTER AT SUITE 141, GREEN CENTER CENTER PRESIDIO POINTE VALLEY, AZ 85614

FEDERALLY FEDERALLY FLOWING WELLS 1323 WEST PRINCE QUALIFIED HEALTH QUALIFIED HEALTH FAMILY HEALTH ROAD, TUCSON, AZ (520) 887‐0800 CENTER CENTER CENTER 85705

MARANA HEALTH FEDERALLY FEDERALLY 2055 WEST HOSPITAL CENTER ‐ OB/GYN ‐ QUALIFIED HEALTH QUALIFIED HEALTH DRIVE, SUITE 115, (520) 797‐0011 NORTHWEST CENTER CENTER TUCSON, AZ 85704 OFFICE

Type Sub‐type Name Address Phone

FEDERALLY FEDERALLY 3690 SOUTH PARK QUALIFIED HEALTH QUALIFIED HEALTH CLINICA DEL ALMA AVENUE, SUITE 805, (520) 616‐6760 CENTER CENTER TUCSON, AZ 85713

1991 EAST FEDERALLY FEDERALLY UNITED WHITEHOUSE CANYON QUALIFIED HEALTH QUALIFIED HEALTH COMMUNITY (520) 625‐8504 ROAD, GREEN VALLEY, CENTER CENTER HEALTH CENTER AZ 85614

FEDERALLY FEDERALLY 2202 WEST ANKLAM WEST SIDE HEALTH QUALIFIED HEALTH QUALIFIED HEALTH ROAD, TUCSON, AZ (520) 616‐6790 CENTER CENTER CENTER 85709

FEDERALLY FEDERALLY 2355 NORTH WYATT QUALIFIED HEALTH QUALIFIED HEALTH MHC PRIMARY CARE DRIVE, SUITE 101, (520) 616‐4948 CENTER CENTER TUCSON, AZ 85712

FEDERALLY FEDERALLY 899 NORTH WILMOT WILMOT FAMILY QUALIFIED HEALTH QUALIFIED HEALTH ROAD, TUCSON, AZ (520) 290‐1100 HEALTH CENTER CENTER CENTER 85711

FEDERALLY FEDERALLY EL RIO COMMUNITY 6950 EAST GOLF LINKS QUALIFIED HEALTH QUALIFIED HEALTH HEALTH CENTER ‐ ROAD, TUCSON, AZ (520) 792‐9890 CENTER CENTER SOUTHEAST 85730

FEDERALLY FEDERALLY 1346 NORTH STONE PIMA PARTNERSHIP QUALIFIED HEALTH QUALIFIED HEALTH AVENUE, TUCSON, AZ (520) 616‐4944 HEALTH CENTER CENTER CENTER 85705

FEDERALLY FEDERALLY 16701 SOUTH SYCAMORE QUALIFIED HEALTH QUALIFIED HEALTH HOUGHTON ROAD, (520) 879‐3527 WELLNESS CENTER CENTER CENTER VAIL, AZ 85641

UNITED COMM FEDERALLY FEDERALLY 2875 EAST SAHUARITA HEALTH CENTER AT QUALIFIED HEALTH QUALIFIED HEALTH ROAD,: SAHUARITA, AZ (520) 576‐5770 SAHUARTIA CENTER CENTER 85629 HEIGHTS

Source: Arizona Department of Health Services. Provider & Facility Database. Retrieved January 18, 2012 from http://azdhs.gov/als/databases/index.htm.

85 X. Community Leader Focus Group

As part of the Pima County Community Health Needs Assessment conducted on behalf of The University of Arizona Medical Center, Carondelet Health Network and Tucson Medical Center, a focus group comprised of leaders from various health and human services organizations in the Pima County service area, including representatives from each of the above‐mentioned health systems, was convened on Feb. 16, 2012 at The Arizona Inn in Tucson.

Note‐takers: Kit O’Connor MS, PhD Candidate ’13, University of Arizona School of Natural Resources and the Environment Alexandra Adams, The University of Arizona Medical Center Christina Geare, The University of Arizona Medical Center

Table Facilitators: Jessamyn Bowling, MPH Student ’12, University of Arizona College of Public Health Emily Coyle, MPH Student ’13, University of Arizona College of Public Health Juliet Charron, MPH Student ’13, University of Arizona College of Public Health

Analyst: Andrew J. Gall, MPH Student ’13, University of Arizona College of Public Health

Themes  Health Status  Issues to Address  Community Priorities

Analysis Framework  Health Status o Populations o Health issues  Issues to Address o Internal to Health Care System o External to Health Care System  Community Priorities o Community Assets o Points of Intervention o Criteria for Prioritization

86 Content Analysis

The participants of the February 16 focus group described three major themes in relation to the Health Needs of Pima County: Health Status of the Population, Issues to Address and Community Priorities. Behavioral Health and Mental Health Treatment and Prevention were the top concerns of the participants.

Health Status Behavioral Health Issues The largest health concern of the participants is the rise in prevalence of chronic conditions in Pima County in recent years caused by unhealthy lifestyle behaviors. The participants focused on obesity, diabetes and cardiovascular disease. These diseases are caused by behaviors such as sedentary lifestyles, insufficient physical activity levels, poor nutritional diets and smoking. These behavioral diseases disproportionally affect lower income and underserved populations.

Mental Health Issues Mental Health Issues of major concern in Pima County are Suicide, Substance Abuse and Mental Illness. Arizona has the highest suicide rate in the United States for adults over the age of 60. Alcoholism, Drug Addiction, Depression, Anxiety, Autism, Mood Disorders and Psychosocial issues are all health topics of concern.

Other Health Issues Other Health Issues of varying levels of concern to participants are oral health, infant mortality, palliative care, immunization, domestic violence, criminal violence and unintentional injuries. Oral Health is linked to chronic conditions. Domestic Violence is linked with income level. Violence is linked to geographic area of residence.

Special Populations Several subpopulations in Pima County are identified by participants: children, young adults, older adults/snowbirds, veterans, prisoners and residents of Southeast Tucson. Some specific subpopulations considered low income, uninsured and/or underserved: homeless people, rural populations, undocumented migrants and Native Americans. Specific health issues are associated with some of these subpopulations:

87 Classification Health Issue Population(s) at Elevated Risk Behavioral Health High Prevalence of Obesity Native Americans, Hispanics, Children, low income Behavioral Health High Prevalence of Diabetes Children, low income Behavioral Health High Prevalence of CVD Children, Native Americans, Hispanics, low income Behavioral Health Inadequate Physical Children, Older Adults, Activity Native Americans, Hispanics Behavioral Health Poor Nutrition in Regular Children Diets Behavioral Health Smoking Young Adults Mental Health Autism Children Mental Health High Prevalence of Older Adults Depression, Anxiety Mental Health High Prevalence of Suicide Older Adults Mental Health Substance Abuse Children, Adolescents, Veterans, low income Mental Health Rehabilitation Prisoners Maternal Child Infant Mortality Children, Young Mothers Health Oral Health Inadequate Dental Care Children, Older Adults Palliative Care Inadequate Palliative Care Older Adults, End‐of‐Life Immunizations Inadequate Immunizations Children, Undocumented Migrants Domestic Child Abuse Children Violence Criminal Violence High Crime Rate Southeast Side of Tucson Unintentional Child Safety (Bicycle Children Injuries Accidents, Drowning)

Issues to Address

Internal to the Health Care System According to the participants there are five major issues to address within the Pima County Health Care System: Availability of Services, Integration of Services, Access to Services, Health Literacy and Health Workforce. 1) Availability of Services: According to the participants Pima County has insufficient chronic, primary and specialty care services. Instead of treating chronic illnesses and behavioral diseases, the healthcare system uses “medication as a Band‐ Aid.” There is a lack of follow up for chronic illness patients who are discharged

88 from the hospitals. In regard to primary care, there are not enough primary care doctors, and there are only two primary care clinics in the county. There are insufficient behavioral and mental health services available at primary care facilities, across all subpopulations. Emergency rooms are being used for primary care by AHCCCS patients and homeless persons. Primary care services need to better address prevention and behavioral health. In regard to specialty services, there are not enough providers, especially in terms of Mental Health. For example, there are no autism services available in Pima County. There is a shortage of psychiatrists. Suicide prevention is not working. Rural populations have less access to specialty services. 2) Integration of Services: According to the participants there are many gaps in services in the Pima County Health System. Physical and behavioral health does not have an adequate continuum of care. Mental and Behavioral Health services are not linked, especially in regards to pediatrics. Many hospitals are not familiar with the services available in the community. There are communication issues between hospitals and other service providers, including Veterans Affairs facilities. There is no cohesive, comprehensive system. 3) Access to Services: According to the participants there are several issues regarding access to health care services in Pima County, mostly related to insurance coverage. First, there is inadequate insurance coverage of the population. Homeless, rural populations, undocumented migrants and Native Americans are often under‐ insured or uninsured. There is a shortage of programs for uninsured populations, who have less access to mental health care and other special services. Often, uninsured people with chronic conditions put off medical care until their condition is life‐threatening, which decreases their quality of life and also increases long‐term health care costs to the system. Second, most behavioral, mental and oral health services are not covered by public or private insurance plans (including AHCCCS). 4) Health Literacy: According to the participants many patients do not know how to interact with the health care system. They are unaware of what services are available and how to interact with multiple providers. 5) Health Workforce: Another issue participants brought up was the shortage of skilled nursing personnel, especially in regard to brain injuries and other debilitating injuries.

External to the Health Care System According to the participants there are several major issues to address outside of the health care system that are directly related to health outcomes and access to services. They fall into three categories: government systems, funding and societal issues. 1) Government Systems: According to participants there are three other government systems outside of the health care system that greatly affect health outcomes in Pima County: Municipal Transportation, Education and Criminal Justice systems. First, Transportation is a major barrier for access to health care, especially for rural populations, older adults and some neighborhoods. In Pima County a car is necessary to get around. There is not enough affordable and accessible municipal transportation for all

89 subpopulations to access health care services. Second, the educational system is not involved enough in health promotion and health education. Physical activity programs have been cut. School lunches are not as nutritious as they could be. Currently, they serve “macaroni and pizza every day.” After‐school activities have been cut, so kids go home and watch television, a sedentary behavior. Third, the criminal justice system is not doing enough with gun control policies to prevent criminal violence. 2) Funding Issues: There is consensus among all participants that all health programs are underfunded at the moment. Many health initiatives have been started with grants, and therefore there is a concern about sustainability of those programs. The Wage index affects distribution of Medicare funds. Participants also feel that Pima County is less funded than Maricopa County because of less representation in the legislature. The Pima County Education system is also underfunded, signifying fewer opportunities for health promotion interventions at schools. 3) Societal Issues: According to participants there are several societal issues that affect health outcomes in Pima County. One major issue is the availability of affordable nutritious food. In Pima County unhealthy food is cheap and fast. Healthy food is expensive and sometimes unavailable in some neighborhoods and communities, sometimes referred to as “food deserts.” Socio‐economic status is a major determinant of health outcomes in Pima County. Lower income populations are underinsured, and often cannot afford health services. Low‐income neighborhoods and communities with higher crime rates have more violence and fewer safe places for physical activity. Undocumented migrants face an additional barrier to accessing health care services because of fear of deportation.

Community Priorities

According to the participants there are several factors to consider in order to address current health issues in Pima County. They fall into three categories: Community Assets, Points of Intervention and Criteria for Prioritization.

Community Assets According to the participants there are three categories of community assets in Pima County that will help address the current health issues: Pima County Community Pride, Accomplishments and Successful Programs. 1) Pima County Community Pride: The participants are very proud of the collaborative grassroots approach that the county takes to solve health problems. The county functions centrally from Tucson with strong connectivity to other communities and the University of Arizona. The hospitals hold quarterly partnership meetings. The county health system is heavily nonprofit, with excellent services such as El Rio that does not turn people away. Overall, there is a strong sense of community that is not present in other parts of Arizona. 2) Accomplishments: According to the participants Pima County has the best

90 acute care in Arizona, some of the best pediatric professionals in the world, strong geriatric care, excellent telemedicine programs for rural communities, strong outpatient clinics for veterans and strong baseline testing for traumatic brain injuries. Policy‐wise, Pima County is committed to smoke‐ free environments, health insurance premium reductions for healthy lifestyles and a “no divert” policy that makes sure that no one is turned away from receiving care. The county is beginning to invest in behavioral health and chronic illness through policies, hiking trails, biking paths and neighborhood access to fresh food. Health facilities are selling healthy food. Schools are paying attention to substance abuse. And, immunization campaigns have been extended to rural areas. 3) Successful Programs: According to participants, several active programs are working well: Women, Infants and Children (WIC); Coalition of Safe Kids; Pima County Access (PCAP); CRC Crisis Response (South Campus); Trauma Center; Arizona Health Village; Arizona Health Education Center (AHEC); Rural Health Initiatives (UA Hospitals); Senior Medication Services; Meals on Wheels; Communities Putting Prevention to Work (CPPW) and El Rio Community Health Centers. According to participants Pima County has 29 Federally Qualified Health Centers (FQHC), one of which is a free clinic.

Points of Intervention According to the participants there are several types of intervention to address major health issues in Pima County. Some are internal to the health care system, while others are external to the health care system. Additional funding is necessary to expand programs and add new ones. 1) Internal to the Health Care System: Health Care System representatives could participate in more community dialogue. Several health services could be expanded, including nutrition, fitness, suicide prevention, immunization, palliative care and telemedicine programs. Hospitals could improve on follow‐up care for chronic illnesses, counseling and discharge planning. 2) External to the Health Care System: In regard to the Municipal Transportation System, public transportation could be more affordable and accessible, especially for seniors and rural populations. In regard to the education system, kindergarten through 12 school programs could improve their health education curriculum, expand their physical education courses, implement healthy lunch programs and bring back after‐school programs to keep children active.

Criteria for Prioritization According to the participants there are two major categories of criteria that could be considered to prioritize the “most important” health issues in Pima County: Health Outcomes and Cost. 1) Health Outcomes: Four criteria include Impact, Co‐Morbidity of Diseases, Longevity and Quality of Care. In regard to impact, important health issues could be considered if they affect more than 50 percent of the population. In regard to Co‐morbidity of diseases, health issues could be prioritized when

91 they are associated with other major health issues. For example, obesity increases the risk for diabetes and cardiovascular disease. In regard to longevity, health issues could be prioritized if they lead to premature death. In regard to quality of care, health issues could be prioritized if quality treatment is available. 2) Cost: Two criteria include Resources and Value to Community. In regard to resources, health issues could be considered based on their overall costs, including cost to the health care system and community through taxes, cost to family, and cost to third parties. In regard to Value to Community, health issues could be considered based on their perceived value to the community. For example, the shooting in Tucson on January 8, 2011, made mental health a major issue for the public.

XI. KEY INFORMANT ANALYSIS

Input from people in the community identified as key informants was an important part of the Community Health Needs Assessment. Stakeholders from the three major health systems (Carondelet Health Network, Tucson Medical Center and The University of Arizona Medical Center) identified key informants based on areas of focus and expertise in the community’s health.

A questionnaire was developed with input from Brad McKinney, division manager of Records and Administration, Pima County Health Department, with the intent of identifying community health needs surrounding the following topics:

 Top Three Health issues

 Accessibility and Adequacy of Services o Primary Care o Inpatient Care o Emergency/Urgent Care o Mental Health and Substance Abuse

 Adequacy of programs to promote healthy lifestyles, including recreational activities, programs and facilities

 Environmental concerns/hazards

 Transportation

Due to limitations in time and resources, face‐to‐face interviews with key informants were not feasible. Rather, based on the recommendation of faculty at the University of Arizona Mel and Enid Zuckerman College of Public Health, the

92 questionnaire was distributed in written form with open‐ended questions. More than 45 questionnaires were distributed in early February 2012 via email to key informants identified, and follow‐up phone calls were made to ensure receipt of the questionnaire. A total of 15 respondents were willing to be identified as key informants and permitted their completed questionnaire data to be included in the analysis.

Top Three Health Issues:

The most common issues that respondents identified were related to access to care, specifically, lack of insurance coverage, cuts in AHCCCS funding, limited coverage for behavioral health, lack of access to medications and funding for primary care. Regarding medical health issues, the top three issues mentioned were obesity, diabetes and substance abuse. These issues are either among or closely correlated with many of the top ten causes of death among Pima County residents, including cardiovascular disease, accidental injury, cerebrovascular disease and drug‐induced deaths.

Accessibility and Adequacy of Services

Primary Care Twelve of the 15 respondents indicated that primary care in Pima County was poor, limited or inaccessible. Specific populations that faced difficulty with primary care access include the elderly, people who have been dropped from AHCCCS, the unemployed, the Native American population and people with mental/behavioral health needs. Regarding adequacy of primary care, a common theme among respondents was that services were adequate for the middle class and the insured. However, the majority of respondents indicated that primary care services are inadequate, indicating a shortage of primary care providers, long waiting times/a shortage of available appointment time and a lack of coordination among service providers, especially for the elderly.

Suggestions for improving the adequacy of primary care include restoring cuts to AHCCCS, restructuring of Medicare payments to physicians, better coordination of care, specifically through encouraging establishment of a medical home; increased health system collaboration/outreach to volunteer organizations that support underserved populations to help understand current needs and issues; better utilization of interpreter services; making Pima County more attractive to physicians through tort reform; encouraging utilization of primary care among special populations that do not always seek early care such as Native American, Black and Asian; linking primary health services with programs that provide free/low‐cost nutrition/fitness programs; community support for immunizations; improving transportation; encouraging increased presence from Federally Qualified Health Centers; and supporting health care workforce development.

93 Inpatient Care Some respondents indicated that inpatient care is readily accessible in highly populated areas of Pima County but accessibility is lacking in rural areas. Also, a few respondents indicated the need for better accessibility to and treatment for mental health care. Several respondents indicated a lack of experience/knowledge in the area of inpatient care and only one indicated that inpatient care is very accessible. Further, patients with limited English proficiency experience greater difficulty navigating inpatient care services. Regarding adequacy, respondents indicated many of the same issues as with accessibility, such as rural areas being underserved and the complication of navigating health systems. Again, mental health inpatient care services are inadequate.

Suggestions for improving the adequacy of inpatient care include: restoring AHCCCS and Mental Health Systems cuts; increasing ambulatory and inpatient services in rural areas; developing resources for those unable to qualify for any type of healthcare coverage and supporting mental health by first acknowledging that Pima County is not meeting the mental health needs of children and adults, providing long‐term care for mentally ill children, and providing education support to their families.

Emergency/Urgent Care Regarding accessibility of emergency/urgent care, it is important to note that there is only one Level I trauma center for all of Southern Arizona. While most respondents indicated that there are often long wait times for emergency rooms and urgent care centers, which may discourage people from waiting to be seen, there is also the concern with urgent care “look‐alikes” that pose as primary care facilities, which may encourage people to visit these facilities instead of seeking primary preventive care. Two respondents stated that emergency/urgent care services are very accessible; a point was made that they are “almost too accessible as so many are using ER care as a doctor’s office.” In terms of adequacy, most respondents indicated that services are adequate, with the exception of long wait times.

Suggestions for improving the adequacy of emergency/urgent care include attaching urgent care centers to hospitals, which would allow emergency rooms to be reserved for true emergencies; expanding funding and offering “wellness clinics” to those who are primarily utilizing emergency rooms for general/primary health care.

Mental Health and Substance Abuse Most respondents indicated that mental health and substance abuse services within Pima County are inadequate and inaccessible, with the most underserved being those without health care coverage. There is a shortage of psychiatrists for elders, and “services are cost‐prohibitive to low‐income individuals given the current status of public health funding in Arizona.” Further, insurance – regardless of whether public or private – rarely covers the cost of inpatient care. Individual

94 organizations that serve a specific population may have sufficient in‐house care, but patients often encounter difficulties when referred out.

Adequacy of programs to promote healthy lifestyles

Respondents’ input regarding the adequacy of programs to promote healthy lifestyles, including recreational activities, programs and facilities were mixed. Regarding adequacy of programs to promote healthy lifestyles, approximately half of the respondents indicated that Pima County is doing well; yet others indicate that funding shortages and a lack of transportation pose challenges in accessibility. Further, costs have increased for programs such as KIDCO which limit availability for low socioeconomic groups. Local programs, such as those offered through Marana Health Clinic and the Pima Council on Aging, offer educational and health promotion programs for the community. For the most part, respondents indicated that residents receive information about these programs through word of mouth, the media, well‐being promoters, advertising and other programs.

Environmental concerns/hazards

The most common environmental concerns/hazards identified by respondents include water quality, including ground water contamination and wastewater treatment; air quality, including blowing dust, allergens and lead; and insect infestations in low‐income housing. Additional issues include mining, lack of neighborhood lighting, lack of safe sidewalks and potholes.

Transportation

Most respondents indicated that the transportation needs of the community are great, especially among low‐income, elderly and disabled populations. Rural populations also face challenges with transportation, and costs are significant for those who must travel to rural health centers and may even have to forgo service. Transportation is available through AHCCCS taxis, but finding transportation for specialty appointments or even shopping is an issue for certain populations.

Further, additional bus routes are needed, roads require repair, walk able routes and bike paths should be a planning focus and transportation connecting central Tucson with outlying areas is needed.

Adequacy and accessibility of recreational activities, programs, and facilities

Most respondents indicated that resources and opportunities for recreation exist within the community. Organizations such as the YMCA, Boys and Girls Club, schools, YWCA and the Refugee Youth Coalition promote engagement in

95 recreational activities. Parks, gyms, hiking and biking trails are adequate. Challenges for utilization include limited time and finances, transportation, language barriers, safety in parks, limited/reduced hours for recreation centers, parks and public swimming pools, lack of promotion of available opportunities and funding cuts for public programs.

96 XI. APPENDICES

Appendix A: Focus Group Content Analysis Outline

Themes  Health Status  Issues to Address  Community Priorities

Analysis Framework  Health Status o Populations o Health Issues  Issues to Address o Internal to Health Care System o External to Health Care System  Community Priorities o Community Assets o Points of Intervention o Criteria for Prioritization

Detailed Outline

 Health Status o Health issues . Behavioral Health  Prevention of Chronic Conditions o Obesity o Diabetes o CVD  Unhealthy Lifestyles o Sedentary Behavior o Not enough Exercise o Poor Nutrition . Cheaper to eat fast food than healthy food.

97 o Smoking  People putting off non‐life‐threatening care . Mental Health  Suicide o AZ has highest suicide rate in U.S. for ages >60  Substance Abuse o Alcoholism o Drug Addition  Mental Illness o Depression o Anxiety o Mood Disorders o Psychosocial Issues o Autism . Oral Health  Linked to Chronic Illness . Maternal Child Health  Infant Mortality  Young Mothers . Palliative Care . Immunization . Domestic Violence  Child Abuse . Criminal Violence  SE Side‐ high crime rate . Unintentional Injuries  Bicycle Injuries o Special Populations . Children . Young Adults . Older Adults/Snowbirds . Veterans . Prisoners . Residents Southeast Tucson . Low Income/Uninsured Populations  Homeless  Rural Populations  Undocumented Migrants  Native Americans

Classification Health Issue Population(s) at Elevated Risk Behavioral Health High Prevalence of Obesity Native Americans, Hispanics, Children, low income Behavioral Health High Prevalence of Diabetes Children, low income Behavioral Health High Prevalence of CVD Children, Native Americans, Hispanics, low income Behavioral Health Inadequate Physical Children, Older Adults, Activity Native Americans, Hispanics Behavioral Health Poor Nutrition in Regular Children Diets Behavioral Health Smoking Young Adults Mental Health Autism Children Mental Health High Prevalence of Older Adults Depression, Anxiety Mental Health High Prevalence of Suicide Older Adults Mental Health Substance Abuse Children, Adolescents, Veterans, low income Mental Health Rehabilitation Prisoners Maternal Child Infant Mortality Children, Young Mothers Health Oral Health Inadequate Dental Care Children, Older Adults Palliative Care Inadequate Palliative Care Older Adults, End‐of‐Life Immunizations Inadequate Immunizations Children, Undocumented Migrants Domestic Child Abuse Children Violence Criminal Violence High Crime Rate Southeast Side of Tucson Unintentional Child Safety (Bicycle Children Injuries Accidents, Drowning)

 Issues to Address o Internal to Health Care System . Available Health Services in Pima County  We have a lower level of care/services than other states.  Chronic Illness Services: Inadequate care in Pima County

99 o G1Q1: “Medication as a Band‐Aid” o ‐Lack of healthcare system addressing chronic illness o Lack of Post‐Hospitalization follow‐up care for chronic conditions  Primary Care Services: Inadequate care in Pima County o There are not enough primary care doctors. There are only two primary care clinics here o Inadequate level of behavioral health services at primary care level. That is across all populations. . Inadequate services for substance abuse . Need more Behavioral & Mental Health Services especially in Pediatrics . Especially juvenile behavioral health. Lack of psychiatrists. . Veterans] o Need more prevention within physician offices o ER used as primary care . AHCCCS patient load is between 60 and 70 percent in the ER. They are using the ER as their primary care. . Homeless use ER as primary Care ‐Where do you discharge them to? There is no place to send them. . People putting off non‐life‐threatening care, impacts cost once it becomes an emergency.  Specialty Services: Inadequate Specialty Services in Pima County o No Autism Services o Mental Health: Insufficient number of psychiatrists o Mental Health: Suicide prevention is not working. o Particular problem for Rural Populations o Don’t stack up as well compared to Phoenix in specialty care . Integration of Health Services  Lack of cohesive system; gaps in the system

100  Physical and behavioral health do not have a good continuum. People don’t know what is available. We have tried to interface with the VA with no success.  Mental and Behavioral Health – especially pediatrics – not linked to one another  Integration of medical and behavioral health; need more to be done so they work together  Many hospitals do not understand the services in the community as well as they should. It’s not a nursing function  Hospital – transition of care from different services  communication . Access to Health Care Services in Pima County  Inadequate Insurance Coverage o Uninsured Populations . Un‐ and under‐insured  Homeless  Rural Populations  Undocumented Migrants  Native Americans . Lack of available programs for underserved. . Access to mental health services is limited . Rural Populations  Access to Special Services is limited  Need to travel to metro areas for lots of services o Services Not Covered by Insurance . Behavioral and Mental Health Services  Behavioral health is not covered by AHCCCS.  P3: Private and public insurance do not cover much behavioral health. . More mental Health Services in jails . Oral health is paid for with discretionary income.  There’s no pharmacy open 24/7 in Green Valley.

101 . Health Literacy – Patients don’t know how to Interact with System  They don’t know what is available as far as access and what is available.  They don’t know how to interact with multiple providers.  If you aren’t educated, don’t have access to primary care, you aren’t going to live as long. . Health Workforce  Lack of Skilled Nursing, especially for patients with brain injuries and debilitating injuries

o External to Health Care System . Government Systems  Municipal Transit System o More difficult for Rural Populations to access care o Public Transportation is lacking in Tucson, a car is necessary to get around o Access to healthcare services‐Transportation; o Disparities between different neighborhoods o Transportation needed for seniors – affordable and accessible o Lack of options to fix problem of transport.  Education System (Schools) o Health Education – we are not teaching because it costs money (general agreement) o Nutrition and physical health have gone down. Macaroni and pizza every day. o After school activities cut, so kids go home and watch TV  Criminal Justice System o Gun Policies . Funding Issues  Inadequate Funding for health programs o General consensus that almost everything is underfunded – nothing to cut

102 o Many health initiatives have been started with grants – there is concern about program sustainability when grants are up. o CPPW ‐ obesity prevention grant coming to an end o Wage index affects Medicare payments ‐ Distribution of funds because of wage index o Not having Legislature that Maricopa County has affects us. We don’t have as many representatives in Legislature as in Maricopa County and that effects funding. Finances are something we compete for. We don’t have as much of a benefit as Maricopa County.  Inadequate funding for education system/schools o After school activities cut, so kids go home and watch TV. No resources to go into schools to fix this. Schools cut physical activities and arts

. Societal Issues  Availability of quality, inexpensive nutritious food o Cheaper to eat fast food than healthy food. o Good food is expensive o Food deserts  Children have little access to safe places to play  Homeless use ER as primary Care. Where do you discharge them to? There’s no place to send them.  Education Level o If you aren’t educated, don’t have access to primary care, you aren’t going to live as long.  Legal Status o Citizenship as a barrier to healthcare o Fear/Immigration Status  Income Level o Domestic Abuse and Child Abuse linked to Income o If you don’t have money – hard to get a doctor  SES o Kids are more sedentary than we were as kids

103 o P3: Some has to do with SES (socioeconomic status)  Crime o Massive gap in neighborhoods; some are healthy, some not. Crime, unsafe areas affect healthiness.  Weak infrastructure in communities – no bike paths in lots of areas

 Community Priorities o Community Assets . Pima County Community Pride  Community Collaborative Grassroots Approach To Problems, “Take Care of our own”  Strong University of Arizona collaboration  Nonprofit Health Services , such as El Rio, that do not turn people away  Function as a single unit Tucson and other communities in Pima County (good centralization)  Quarterly Hospital Partnership Meetings  Healthier than Phoenix, stronger sense of community than Phoenix . Accomplishments –to Date  Best Acute Care in Arizona  Best Pediatric Professionals in the world  Strong Geriatric Care  Hiking/Walking Trails and Biking Paths  Being outside = healthy  Telemedicine for Rural Communities  Neighborhood access to fresh food  Health Insurance premium reduction for healthy lifestyles  Extension of Immunizations to Rural Areas  Healthy policies and programs at health facilities o Smoke‐free campus o Healthy food for sale  Baseline Testing for Traumatic Brain Injury  Awareness of sports‐related injury risk

104  We are doing a lot to address chronic illness, diabetes care, obesity prevention, child injury prevention at UAMC through outreach  Schools pay attention to drug abuse  Coordination of Care for depression (cuts cost)  Starting to invest in behavioral health  “No divert” policy  Strong VA hospital w/out‐based clinics and they make a difference  Anti‐tobacco – commit to smoke‐free policies  AAA‐ Aging . Successful Programs  Women, Infants and Children (WIC)  Safe Kids  Coalition of Safe Kids  Pima County Access (PCAP)  Crisis Center – CRC crisis response (UAMC South Campus)  Trauma Center  AZ Health Village  Federally Qualified Health Centers (FQHC) at 29 sites and free clinic  El Rio Community Health Centers  Rural Health Initiatives (UA hospitals)  Arizona Health Education Center (AHEC)  Senior Medication Services  Meals on Wheels  Immunization Programs  Communities Putting Prevention to Work (CPPW)  Veterans Affair Hospital  Outpatient Clinics o Points of Intervention . Internal to Health Care System  Health System/Community Dialogue  Expansion of Health Services o Suicide prevention Programs o Health education . Behavioral Health . Immunization

105 o Exercise/Fitness Programs o Nutrition Programs o Palliative Care  Hospital specific Interventions o More Post‐hospitalization follow‐up care for chronic conditions o Counseling, drug abuse, substance abuse facilities for people without means. o Discharge planning  More Telemedicine, especially for Rural Populations . External to Health Care System  Schools/Education System Specific Interventions o Stronger health education – pre‐K‐12 education o School‐based exercise and diet education o Healthy lunch programs o Improved Physical Education and Health Education programs o Afterschool programs to keep children active and away from the TV  Transit System o Transportation for seniors – affordable and accessible  Funding: Need more funding o Criteria for Prioritization . Health Outcomes  Longevity o If it makes everyone die young  Co‐morbidity of diseases o E.G. Obesity, Diabetes, Heart Disease  Quality of Care . Cost  Resources at different levels o Medical costs, family cost, community taxes  Impact o Affecting several people and specialties all at once‐ impacts care of others, 50 percent or more?  Value to community/Quality of life o Public Perception by the public – Jan. 8th 2011 shooting made mental health a big issue; Jan. 7th may not have been important

106 Appendix B: Key Informant Questions and Complete Responses

Pima County Community Health Needs Assessment ‐ Answers to Key Informant Questionnaire

1. What are the three (3) most important health issues in Pima County? Access to care, services for those with no health coverage, funding for primary care/prevention programs Lack of insurance coverage, inadequate prevention services, lack of access to medications, adequate low‐cost clinic options, low‐cost dental services, length of time Medicare beneficiaries must wait for referrals and prior authorizations through the Medicare Advantage system, adequate mental health services Lack of health insurance for a sizable part of the population, especially since the recent AHCCCS cuts. Lack of mental health services which could prevent more costly hospitalizations. Lack of sufficient affordable in‐ home services for elders, which could prevent more costly hospitalizations Underinsured and uninsured population, non‐compliant patients, prescription drug abuse; behavioral health ‐depression and anxiety, substance abuse, domestic violence; medical ‐ diabetes, obesity, asthma and hypertension Uninsured/under‐insured residents of Pima County includes undocumented residents; behavioral health coverage; lack of dental coverage Affordable mental health care for children, affordable mental health care for adults, adequate/appropriate mental health care services for children and adults Affordability, oral health, obesity Funding for the people that don’t meet AHCCCS criteria anymore. Only 25 days covered per year for those that do have AHCCCS – this means lots of people who suffered injuries do not have access to acute rehabilitation anymore. Access to primary care physicians. The three most important health issues concerning refugees are: 1. Personal and home hygiene (creating a healthy living environment, free of bed bugs, roaches and bacteria); 2. Dietary and exercise‐based education (for clients, understanding how diet and exercise impacts chronic and/or acute illnesses); 3. Women’s Health (including yearly checkups, family planning and support) a. Increasing barriers to accessing the appropriate acuity of medical and behavioral health care arising from reductions in public program funding for vulnerable populations in all areas of service (mental health, children and pregnant women) and limitations by health insurance plans. b. Prevention and management of chronic disease including obesity, hypertension, diabetes, cardiac and respiratory. c. Limited coverage by health insurance plans for behavioral health services; continued stigma associated with seeking behavioral health services; difficulty for the public in identifying pathways to access behavioral health services i.e., crisis and counseling; need for an expanded continuum of cost effective service alternatives to meet the needs of a diverse population. Chronic Diseases, Obesity, Substance Abuse 1. Changes and cuts to AHCCCS 2. Diabetes (specifically within the Bhutanese community) 3. Lack of knowledge around navigating the health care system

107 Adequate coverage of mental health Aging population health Lack of adequate funding for both issues mentioned above Obesity prevention, diabetes, cardiovascular health  Transportation to health services  Paying for health services for those with health insurance (co‐pays) and those without health insurance, how to pay for services.  Access to preventive services or preventive activities: parks, walking trails, fresh food/farmers markets.

2‐a. How accessible are primary health care services in Pima County? El Rio serves 76,000 registered patients and we do have capacity to serve more. I think the bigger need is an awareness campaign about establishing a medical home. Difficult for people who have been dropped from AHCCCS, wait time for appointments are long, transportation to appointments is difficult, original Medicare beneficiaries must find their own PCP’s Not sufficiently accessible to people with mental health issues or the unemployed or adults with no children who aren’t covered by their employers. BH‐Accessibility has been more difficult with the cuts in behavioral health. Many BH clients are now Title XIX which now means their benefits are substantially cut. Medical‐There are a growing number of points of service but not all serve low income. Challenges exist for those without insurance or who have been denied access. Better over the past three years as far as locations of CHCs – additional clinics now available on the far East side where services had been very limited. Transportation still remains a challenge. Still a bit difficult for special populations. They are accessible but not necessarily convenient or timely when families are new to Pima County Very poor, especially for working poor There is a shortage of primary care physicians which will only become more critical. Primary health care is adequately accessible for refugees. Most know how to get to their PCP by bus, or can use the taxi. Most problems stem from clients unable to receive timely appointments from larger clinics (like UAMC and El Rio) or having smaller clinics schedule weekly (or sometimes even biweekly) appointments for clients without assisting with transportation. Some refugees also have $3.40 copays, which are impossible to pay (if their cash assistance is finished and they have $0.00 income and do not qualify for SSI or their SSI is pending).

Pima County has a significant population located in federally designated health professional shortage (HPSA) and medically underserved areas (MUA). i. 27% in HPSA primary care, ii. 55% in HPSA dental care, iii. 100% reside in low income HPSA behavioral health and iv. 31% in medically underserved area. Relatively accessible, but remain challenging for many Limited. The biggest access barriers for refugees are language and transportation. Limited office hours for PCPs is a huge issue as well. Refugees can’t easily schedule appointments, check in at front desks, fill in paper work and communicate with their providers. Judging from client interaction, not readily accessible

108 Very accessible Appointment for primary care can take a long time. People are seen quickly for emergency/urgent situations versus primary care.

2‐b. How adequate are primary health care services in Pima County? Adequate – state/federal cuts this year will put great pressure on a system that is already delicate Doctors spend little time with their patients, wait times in offices can be long which is difficult for elderly individuals, have to go somewhere else to have lab and x‐rays which can be difficult if you do not have transportation

If you have insurance they can be quite good, but again those without insurance are without recourse. Primary health care providers are scheduled and same day services are limited. A shortage of qualified providers puts a strain on the clinic operations as well as pressure on the providers to maximize schedule time and provide quality care to their patients. Additionally, an aging population is in need of chronic care services which require coordination and time to educate collaborate and assist older adults with explanations about medical appointments, processes and how to properly take medications. There is still a shortage as far as having enough providers and appointment times to meet the needs of those working adults and families with children. Need to improve extended hours and same day appointments for urgent issues to avoid ER use. Services and/or support for vision, dental and mental health are severely in need for Pima County Fine for middle class There is a shortage of primary care physicians which will only become more critical. Some primary care facilities still do not use interpreter phones, or use one phone and use it for the whole family for one appointment. Doctors or clinics insist on scheduling 15 or 30 minute appointments for refugees, when it typically takes twice as long due to interpretation. I think there are still some cultural and/or trauma‐related misunderstandings between patient and provider, where refugees find working with doctors frustrating and do not want to actively engage or do what they are asked to do, but at the same time doctors do not understand past issues that may contribute to their current issues or get frustrated when refugees do not do what they are asked to do, but may have been easily solved by accommodating for cultural differences (such as Somali women only having female doctors or doctors telling Nepali patients to stop eating rice, when realistically that is their staple food). Primary care services are adequate for those individuals with some form of health insurance. However, for those who are uninsured or underinsured or living in more rural areas, access is more limited since providers are reluctant to engage in treating individuals without a payer source. I do not have a good sense of this issue It’s amazing how many AHCCCS PCPs don’t use interpreter language services even though they are mandated by federal law. Not adequate Adequate Primary health care physicians need to provide better preventive information. Most of the doctor’s visits/talks focus on the disease or problem. In my visits with my PCP, we focus a very small time on eating better and exercising.

2‐c. If you view primary health care services as inadequate, how might the need be addressed?

109 Encourage more physicians to consider having lab services in their offices; more education for providers on alternative and complementary care services, needs of lesbian, gay bisexual, transgender elders; payment structure for physicians must be revisited for Medicare, medical students need to be encouraged to go into family internal medicine Immediately restore recent cuts to AHCCCS and the mental health system The concept of medical home is intended to improve the coordination of care. However the staffing 2 requirements involve costs which are not billable. Increasing overhead, improving care and maintaining a sustainable operation requires planning and a qualified workforce. Pima County should be positioned to support community health centers with community efforts for immunizations, pediatric and senior, in the forms of vaccines and licensed manpower. Continue work on extended hours and workforce issues around those extended hours and key locations; Continue education and outreach to encourage use of primary care to special populations such as Native American, Black and Asian that do not always seek care early Eligibility is difficult to navigate for some families, service providers are lacking in the mental health arena and transportation is frequently an impediment for families. Reinstate AHCCCS cuts and KidsCare We need to make Pima County more attractive to physicians. One way would be tort reform. Medicare needs to stop cutting physician fees as well. Medical school is very expensive and takes a huge commitment. Many of these medical students as feeling that working in a primary care practice is not financially rewarding. I think having those doctors and health care services reach out to the VOLAGS and ask for assistance can really help bridge the barrier between patient and provider. VOLAGS (such as the IRC) can answer questions about refugees or help with understanding current issues or needs. This new knowledge needs to be spread throughout the health network in Tucson. Encourage a greater presence from the Federally Qualified Health Centers which exist to serve low‐income populations. Support health care workforce development including not only physicians, nurses and pharmacists but also allied health professionals and other personnel who can facilitate lower cost access and/or compliance with care. Interpretation services need to be utilized by every provider. It’d be helpful if front desk persons used language line/cyracom as well. Cultural training and Refugee 101 seminars would be helpful as well for providers. More comprehensive qualifying criteria and funding N/A Linking primary health services with programs that provide free/low‐cost nutrition/fitness programs.

3‐a. How accessible are inpatient health care services in Pima County? Somewhat accessible ER is over used, services are accessible if you have insurance and then the insurance dictates the type of care, care is often dependent on the resources the person has Again, not at all accessible to many people BH‐There is a need for treatment and not housing Medical‐in Marana there are no assisted living sites. While there are plenty of hospitals within the Tucson city limits, the rural areas lack inpatient services and people tend to utilize the rural clinics for acute services when they should go to an ER. Good access in the very populated areas of Pima County still an issue for folks in the more rural areas such as Ajo.

110 There is such a difference between the need for “health” care and “mental health” care that this is really a two‐part question. While Pima County appears to me to have accessible inpatient health care in general, it has almost no mental health inpatient health care services. Don't know Very accessible. It is extremely hard for patients with limited English proficiency to navigate inpatient health care services. Not only are they rarely within the SunTran bus limits, but AHCCCS taxis are unreliable and the IRC only has so many interns and volunteers to help with transportation. Also, if a refugee misses one appointment (for example, if the taxi does not show up) then it take up to two months to reschedule and refugees sometimes get stuck with a $25‐$50 no‐show fee. For general medical issues, inpatient health services are satisfactory, but given the current utilization of inpatient services and the lack of residential or outpatient service options, there is a perceived shortage of psychiatric inpatient beds for adults and youth. I do not have any specific experience in this area I’m unaware of this. Most my knowledge is around PCPs. Not familiar with this issue Very accessible Adequate. We have several hospitals in Tucson/Pima County, however most are in the urban areas and few in suburban/rural areas. Health clinics then become crucial to health services for rural folks in AZ.

3‐b. How adequate are inpatient health care services in Pima County? Sometimes complicated systems to navigate Patients and their families must be their own advocates as Medicare coding dictates hospital/rehab stays Pretty good if you have insurance Non‐existent Medically, Tucson has a fair number of inpatient health care facilities which provide inpatient services to the county, however given how large the county is, the rural areas are very underserved. Our organization finds them good except for elective admissions then we see some delays and limitations. Direct admits from ER are good. While there appears to be adequate inpatient healthcare in Pima County, that does NOT include the need for inpatient mental health care. Mental health care is practically for all practical purposes non‐existent in Pima County. Don't know Very adequate.

I would say not adequate enough for refugees, particularly those facilities that see a high number of refugees (like orthopedics, ENT, cardiologists) but refuse to provide culturally appropriate health care services. Adequate I do not have any specific experience in this area Not familiar with this issue Adequate Adequate, again in rural areas, there are little to non‐existent inpatient services. On the reservations in Pima there are no inpatient services other than for emergency services.

3‐c. If you view inpatient health care services as inadequate, how might the need be addressed?

111 More reasonable hospital stays to avoid readmissions for the same condition Restore AHCCCS and Mental Health System cuts Both must be constructed in the rural areas. Medically, there needs to be an increase in the inpatient and ambulatory services in rural areas. Resources for those still unable to qualify for any type of healthcare coverage. The hospitals do a wonderful job with limited resources but a way to ease the total burden of those primarily in the 0‐100 FPL that do not qualify for coverage needs to be addressed somewhere in the healthcare system in Arizona and Pima County. Acknowledging that Pima County is not meeting the mental health needs of children and adults; provide long term care for mentally ill children that includes a wide variety of support that would include educational support as well as family support N/A If health care services need more information regarding refugees, they should contact a VOLAG for an orientation, or the Primary Care Physicians Workgroup that already does Refugee 101 training. Language lines are a must, particularly with these delicate and serious issues. N/A N/A N/A

4‐a. How accessible are emergency/urgent care services in Pima County? There is an increasing number of options Long wait times in ER, urgent care centers are crowded also These services are more accessible due to federal regulations, but unfortunately the waiting time in ERs discourages many people from staying until they are seen. There are multiple locations for those to see service. Some commercial organizations are being built and then are looking to “book” appointments with patients for follow up such as Fast‐Med. The Urgent Care “look alikes” are posing as primary care facilities and reinforcing the practice of seeking care only when there is an issue rather than promoting preventative visits. There multiple locations in which residents of the county can seek emergent care. Again, these are located in the populated areas and those in the rural areas lack close access to facilities. There are situations in which time means everything (stroke, heart attack, etc) and the travel time can be very detrimental. There seem to be enough facilities in locations that can be accessed but wait times I believe remains an issue at the ERs and urgent care centers often must direct patients to the hospitals. Very accessible; almost too accessible as so many are using ER care as a doctor’s office. Don't know Very accessible. Clients are given trainings on whether their nearest emergency/urgent care services are and have cards, which give their names and language needs. Most of them know how to call 9‐1‐1 and how to take clients to the ER. However, there are some issues with refugees not understanding what constitutes an ER/Urgent Care visit and the difference between the two. We are currently working on re‐training clients and giving them orientations to help alleviate this problem. There is only one Level I trauma center for all of southern Arizona. The emergency management response for this region may not be sufficient without a strategy to leverage the Level I center with another Level I center or several lower level trauma centers designated as Level II, III or IV. The recently approved level III designation for the hospital at the south campus that is tied to the Level I trauma center should expand trauma services for the region.

112 I do not have any specific experience in this area Less about accessibility and more about over utilization. It is where refugees go when they should be seeing a PCP. However they have the same issues in emergency/urgent care as they do with the PCPs. Not current with this issue Very accessible There are several Emergency Services in Pima County. With the development of NextCare and others, there are now urgent care facilities on the Southside of Tucson. Before I would have to travel to park/Ajo, now I can go to 1‐19 and Irvington which is closer, but still takes 20 minutes from house in the county. I am not sure about Green Valley, Vail or other outlying communities.

4‐b. How adequate are emergency/urgent care services in Pima County? Adequate – emergency rooms sometimes overcrowded Need education as to when you go to ER or Urgent Care, clients report eight or more hours waiting in ER They do not meet the need Plentiful. There are numerous emergent/urgent care services in the county, however, we would benefit from having additional level 1 trauma centers. Somewhat inadequate Very adequate with the exception of, at times, extremely long waits for care. Shortage of neurosurgeons, especially on the weekend. Emergency/urgent care services are adequate. It is difficult to monitor whether they provide language lines for those with limited English proficiency, but overall I would say that refugees are treated well and are given the health care they need in these emergency situations. The opening of the psychiatric urgent care crisis center approved by voters in the 2006 bond election is making a difference in the utilization of emergency rooms throughout the area which should increase the access to those facilities for true emergencies. On average per month 85 youth and 457 adults are accessing these services with 62 admissions per month for a short term stay at the 15‐bed sub‐acute unit. Approximately one third of the youth and adults presenting to the crisis center are transported there by law enforcement which has embraced this site as its destination rather than utilizing emergency rooms. Same interpretation issues. N/A Adequate I have visited both urgent and emergency, I am satisfied with urgent, but not with emergency. Emergency services still take too long to be seen. When I had an allergic reaction and had a hard time breathing, I drove myself to ER, barely explained my situation and was made to wait several hours to be seen. When I was seen I received immediate relief. Parking was an issue at UMC, I did not know where to park and could not walk far because did not know if I could walk far without because it was difficult to breath.

4‐c. If you view emergency/urgent care services as inadequate, how might the need be addressed? Education, attach urgent care centers to hospital emergency are allowing patients to be seen at urgent care and leaving emergency rooms for true emergencies Expand funding for these services. Promotes drive thru medicine rather than continuity of care by one’s established provider.

113 This is a complicated question because much of what creates the wait times in the ER are persons delaying care for colds etc. or reasons other than the ERs or urgent care services being available. Delay in addressing a health condition. A person not being able to determine whether the condition can be handled at an Urgent Care versus hospital level etc. Offering “wellness” clinics, etc., for those who traditionally are using the ER’s for general health care. N/A Same as PCP. N/A N/A Better parking, better ways to triage/stabilize patients while they wait to be seen.

5. How adequate and accessible are mental health and substance abuse services within Pima County?

Limited services The elimination of State funding for these services has left many who no longer qualify for mental health services searching for meds they can afford, elderly individuals could benefit from in‐home counseling, to few psychiatrists for elders Very inadequate As with most of the country, mental health and substance abuse services are severely lacking. I personally do not feel they are adequate or accessible primarily related to healthcare coverage. If no coverage not affordable for most seeking care Mental health services are sorely lacking; substance abuses are adequate and abuse services could be improved with increased housing for victims and their families. Inadequate Don’t know. I do not work with mental health services within Pima County.

a. Outpatient mental health services are accessible for those with sufficient funding; however, services are cost prohibitive to low‐income individuals given the current status of public funding in Arizona. Inpatient needs are not met in this community as services are generally paid for out‐of‐pocket, because insurance (private/public) rarely covers the full cost. Pima County has utilized bond funds approved by voters to build two significant facilities to treat behavioral health conditions and also funds the operating costs of the local Regional Behavioral Health Authority. b. Substance abuse services have expanded during the last year through the opening of a 12‐bed facility known as Desert Hope on Ajo Way. c. For those approximately 40,000 individuals per year whose behavioral health and/or substance abuse conditions result in behaviors creating entry into the criminal justice system, the Pima County Adult and Juvenile Detention Centers provide an array of medical and behavioral health services as well as specially structured substance abuse services. I do not have any specific experience in this area Relatively good, IRC has in house mental and behavioral health services, but when we refer out for issues beyond our abilities (i.e. mental health requiring subscriptions) same issues as PCP. Not adequate Very adequate and accessible Not sure.

114 6‐a. Does your community have adequate programs which promote healthy lifestyles? Yes/No Limited due to lack of funding for prevention No, a few are getting started but need more funding like the PCOA Healthy Living programs Yes for those with transportation and the initiative to attend the many free offerings. We need more programs in the schools and accessible to non‐English speakers and those without transportation. MHC is putting more focus in this area. Our new Counseling and Wellness Center will have classes in these areas as well alternative treatments. MHC currently offers diabetic education classes and in partnership with the Counseling and Wellness center, will continue to develop educational opportunities for the community. No Yes No Yes I currently have a medical volunteer program where we go into the home and help train clients to navigate the US healthcare system, as well as how to access healthy foods etc. However, there is certainly a lot more we can do to help address these issues and so we are developing a medical orientation for IRC clients to attend. Yes ‐ Eastern Pima County has a large number of services and programs that promote a healthy lifestyle for all ages. Participation is a different issue (see number 9). Yes, I believe so Yes, but more are needed. No Yes No. only if you pay for those services like the YMCA. Even afterschool programs and summer programs like KIDCO which was very inexpensive at first about $100 per year has jumped to $500 per year for afterschool care. Unless you are in a very low socioeconomic group can you access services for free or low‐cost. As a middle income person, the services I access, like the Y or other summer program for my child, I have to pay the full cost.

6‐b. If yes, how do residents obtain information about these programs? Media ‐ word of mouth PCOA advertises its programs but funding for marketing is very limited, doctors need to be educated about programs and encouraged to refer people to them NEVER TOO LATE, newspaper ads, TMC programs Community Outreach and word of mouth. Schools; TV ads; Radio ads; Billboards; Team Sports info Don't know. We have orientations, trainings and in‐home volunteers at the IRC. These clients find out about these programs when they come to the IRC and through fliers. These tactics seem to be doing well. Residents obtain this information via advertising through traditional outlets including radio, TV, and newspapers. Other outlets include the library system, community events and social media. Public libraries, newspaper, internet, educational facilities‐schools, colleges, etc. Well‐Being Promoters (ie: Community Health Workers. Tribal offices, Indian health services (San Xavier and Sells), Tucson Indian Center, Native American health and wellness events.

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Only if you know people who access those services or hear from other people about those services.

7‐a. Please identify any environmental concerns or hazards in Pima County. Water quality. TCE cleanup – sun‐skin cancer rate Homes need to be modified for safety and accessibility when someone is frail and has limited mobility, many of our clients live in old mobile homes that have soft floors, insufficient heating and cooling, dangerous electrical The wastewater plant off of Prince is an issue but I am not aware it poses any public health risk. This may seem an odd answer but there seems to be more issues around asthma and allergies in Pima County. In the 50’s people moved here for the dry weather and no allergies but with them came plants and trees not native to the area. Transportation – potholes, unlit streets, lack of enforcement of pedestrian laws Blowing dust Dust Bed bugs and cockroach infestations are HUGE concerns in Pima County. There is concern over air quality and the impact of mining as well as ground water contamination and hard water. We seem to have a large concentration of lead in our air Low income apartments with bug infestations. Lack of neighborhood lighting. Lack of safe sidewalks. Not current with this issue Roads that do not accommodate for all persons, ages, and abilities to use to obtain access to health services. This also accounts for lack of sidewalks or damaged sidewalks. No enough buses, not enough parks, too many loose dogs, especially in the county which makes it hard to walk in the neighborhoods. Lack of street lights in areas. Drivers do not follow rules for pedestrian cross walks, bicyclist, right turns or fully stop at street lights.

7‐b. What has been the response to these issues? Many of the homes noted above are so worthless rehab programs will not put money into them but individuals cannot afford other housing The new plant is currently under construction. Not sure The “blame game” – no money from the legislature; astronomy concerns; etc. N/A The IRC has done numerous orientations at apartment complexes for refugees regarding these issues and we work directly with apartment managers to help eliminate these hazards, however there are still a lot of problems with re‐infestations and client home hygiene. We also created another orientation for IRC clients to learn more about bed bugs and how they can help prevent contamination. Pima County tightly monitors air quality and ground water contamination and evaluates all mining projects. Unknown Education about home hygiene but when the whole complex is infested there is little a person can control in their apartment. N/A

116 Pima County Department of Transportation has been getting more involved in the role that they can play in public health by creating a built environment that has improved accessibility. Increased bus service, but not for rural areas of the county,

8. What are the transportation needs of people in your community? More options are needed – roads need to be repaired – safe bike and bus routes Transportation is a major issue for older adults, some people need aides to ride along on Sun Van, need more low cost options The bus service doesn’t reach many areas and frail seniors don’t have the stamina to walk long distances to the bus stops MHC rural clients have no transportation. Our transportation costs are significant. If a client has no transportation then unless we transport, they receive no services as there is limited rural public transportation. SunTran has recently begun to travel from the Cortaro area to the Marana Municipal complex. Picture Rocks and Avra valley still do not have services. In addition, there are clients who would need to walk a mile to be able to access transportation. There are still gaps in transportation services in our community. Finding transportation for appointments and for simple shopping needs still is an issue for certain populations. I know this is something that is being addressed currently at the primary care level (CHCs) not sure how folks make it to specialty appointments. Sidewalks, bike lanes and well lit streets and walkways. Safe streets – potholes are so prevalent it is not uncommon for accidents or near‐accidents due to avoiding and/or hitting extreme street damages. More bus service, more bike lanes Don't know Clients typically use the bus or AHCCCS taxis to attend medical appointments. Some clients do have cars, but this is a significant minority within the refugee community. A lot of the “special medical clients” need personal transportation, because we cannot rely on them to attend appointments on their own. A variety of transit options are required to meet the needs for all socio‐economic demographics. Walkable routes and bike paths need to be a focus in all planning. A metropolitan system of transportation that connects central Tucson with outlying areas is needed. I think that many low income individuals and seniors have many needs related to transportation More bus routes, more times, low literacy signs and guides. Lack of reliable transportation for elderly and disabled The transportation needs for urban areas include improved sidewalks and signage for bus and/or shuttle access. For the suburban and rural areas, there is a need for the existence of sidewalks and more bus and/or shuttle stops. Same as above, I wish there were buses that go to the counties.

9. How adequate and accessible are the recreational activities, programs and facilities for residents of Pima County? (For youth, for adults, for seniors, general)

GENERAL: We have lots of options in my opinion for all ages. Challenges become the fact that many people have limited time and financial can also be a barrier.

Outlying areas need more options, transportation to activities often a problem

117 The activities in the area are plentiful if the person and family wishes to engage. YMCA, Boys and Girls Clubs and Schools offer non‐stop team and individuals sports or work out activities. In addition, with the surrounding areas, parks and hiking there is always much to do in the area. The conditioning that is takes for people to believe they can get out and be active comes from the environment, support groups and family. There seem to be adequate parks, gyms etc. Again resources and safety may still be an issue. Pools in the summer have had to raise their rates and some families now given the current economy are unable to fit it into their already stretched budgets. Safety remains a bit of a concern in our parks. In general not too bad; however the hours of swimming pools is atrocious. To have them closed on weekends makes it practically impossible for working families to avail themselves of the pools on weekends. To close them in a city in Southern AZ makes no sense whatsoever, and to ask others to “fund” their operation is an abrogation of city and county responsibilities. The recent court ruling against the Forest Service and its fee for accessing park lands may make them more accessible for some families. We need more; YOUTH: We need more after school services and summer programming Don't know We have our own RYC (Refugee Youth Coalition) which refers refugee youth to recreational activities, programs and facilities. For adults and seniors, we if an IRC refugee comes to the office requesting a service such as this, we refer them to community organizations, such as the Boys and Girls Club, TIARC etc. Most of these services do not have special language groups, so it is difficult for refugees to access all of the resources available in Pima County, since they do not speak fluent English.

For youth: For youth opportunities are available through the YMCA, YWCA and the Boys and Girls club but promotion of recreation and physical activity within the school hours has been reduced.

For adults: The community offers a substantial amount of public facilities in the form of parks, hiking trails, bike trails etc. and also offers private programs.

For seniors: The focus for this group is the availability of safe walking areas within their neighborhoods. Improvements could be made in this regard.

General: For all age groups the opportunities and infrastructure exists, but a lack of promotion results in low‐usage of resources. This creates a cycle of funding reductions as recreation centers, parks, and community pools reduce operational hours or close entirely. Seem to be adequate and accessible Severely limited for all. Language and transportation being the largest access barriers. Cost as well. Funding has been cut for both of these services so they are not in the least bit adequate for all of these age ranges Same as above. For youth: Youth sports leagues are very competitive, there should be Tucson sponsored leagues where all students are allowed to join and play. Tucson Parks and Rec should not have dual registration fees for their programs. County residents, not living in the city pay higher fees, yet there are few or no programs in the county. For adults: Walking clubs. For seniors: More senior fitness activities, rarely do I see seniors at YMCA or Pima County Parks and Rec. Appendix C: Methodology

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Following guidelines set forth by the IRS to engage public health in the assessment process, the health systems contracted a graduate student at the University of Arizona’s Mel and Enid Zuckerman College of Public Health to conduct the assessment and analysis and write the report. The entire assessment process was completed in approximately four months, and while the initial intent of the assessment was to provide a general overview of the health status of the county, throughout the assessment process it became clear that a more comprehensive approach was needed. In addition to secondary, quantitative data on the community demographics, morbidity, mortality and risk behaviors associated with the health status of the community, the assessment also includes primary, qualitative data collected from a community health leader focus group and key informant input. This additional information ensures that the assessment follows guidelines set forth by the IRS that require health systems to take into account “input from persons who represent the broad interests of the community serviced by the hospital facility, including those with special knowledge of or expertise in public health.”

As with any community health needs assessment, several limitations were encountered in the assessment process. First, as previously mentioned, this report is not meant to be comprehensive, but is a summation of four months of research and analysis of the key findings of materials collected by the data analyst. In determining what data to use and how to conduct the assessment, the data analyst elected to follow guidelines set forth by the Catholic Health Association’s February 2012 Discussion Draft Assessing and Addressing Community Health Needs, which was “designed to help not‐for‐profit health care organizations strengthen their assessment and community benefit planning processes.” xxxvi This assessment was also influenced by a similar assessment following the CHA guidelines conducted in 2011 by the La Paz, Arizona Regional Hospital.xxxvii

Further, in order to address a broad range of issues related to the health status of the community, several data sources were utilized, including County Health Rankings, the Arizona Department of Health Services Vital Statistics, Primary Care Area Statistical Profiles, the U.S. Census Bureau and several others. Not all data that was provided was comparable between sources due to formatting, collection methods, and criteria, missing information, and inconsistencies in data reporting time frames. Further, several health indicators were compared with benchmarks set forth by varying ranking methods, and in many cases, indicator rankings were not updated with the most recent data available.

i U.S. Census Bureau. (2010) Arizona State and County Quick Facts. Retrieved January 29, 2011, from http://www.census.gov/ ii U.S. Bureau of Labor Statistics (2010). National Unemployment Rate. Retrieved March 10, 2011, from http://www.bls.gov/cps/

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